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TC and Infertility

“If the cancer is in my testicles, that means I can’t have kids, right?” Wrong!

-Infertility is defined as the inability to conceive a baby.

-In men, infertility results from:
-abnormally shaped sperm
-inability to produce a high enough sperm count
-poor sperm motility

-Many man who have testicular cancer fear that they may never be able to have a baby, but that is not the case! Most men who try DO go on to father children after treatment (8 out of 10).

-In a small fraction of patients testicular cancer is diagnosed as part of an infertility work up. At the time of diagnosis, sperm counts can be low and improves once the testicle is removed. Some treatment options may increase your risk of infertility, but having TC does not mean you can never father children.

-If you experienced fertility troubles before being diagnosed with testicular cancer, it may be harder to have kids following treatment, but is still possible!

-If you plan to have children, talk to your partner and doctors before beginning treatment. Your doctor may recommend you to a sperm bank if you are concerned about your ability to conceive in the future. There, they will freeze and store your sperm until you are ready for a baby later down the road.

Before you start radiation , chemotherapy or need an Lymph node surgery you should discuss sperm banking with your team. Typically 2 specimens are needed 3 days apart. Special blood tests will be done and then sperm is stored. There is a fee associated with sperm banking and you should check with your insurance about it.
-Retroperitoneal lymph node dissection may cause retrograde ejaculation, which can result infertility. Retrograde ejaculation occurs when nerves are damaged during the surgery and sperm no longer exit through the urethra. Instead, they travel backwards and end up in the bladder. Nerve-sparing surgery can reduce the risk of retrograde ejaculation from occurring and can preserve fertility. Look for a surgeon with experience performing nerve-sparing surgery.

-Most men diagnosed with TC only have cancer in one testicle. If only one testicle is removed, then the man can still go on to have children naturally. If both testicles are removed, sperm production is permanently damaged and the man then becomes infertile.

-Chemotherapy and radiation can negatively impact sperm production and quantity, but for most men, this is only temporary. Most doctors recommend waiting 12 months following the end of treatment to begin trying to have children in case sperm were damaged during treatment. There is not much research about the effect of damaged sperm, but it is thought to be linked to birth defects so it is best to wait to be sure!

-A family counselor may be helpful to you and your partner to figure out what option is best for you if you decide you want children in the future. The fear of not being able to have children can cause negative emotional and mental side effects, which a counselor could also help you deal with.

Remember, there are options and you should not be afraid to seek help!

Canadian Cancer Society. Supportive care for testicular cancer. (n.d.). Retrieved from http://www.cancer.ca/en/cancer-information/cancer-type/testicular/supportive-care/?region=on

Cancer Research UK. Fertility – having children after testicular cancer. (n.d.). Retrieved from http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/living/fertility-having-children-after-testicular-cancer

Fertility Factor. Testicular cancer and infertility. (n.d.). Retrieved from http://www.fertilityfactor.com/testicular-cancer-infertility.html

Trimarchi, M. (n.d.). HowStuffWorks “How Sperm Banks Work” Retrieved from http://health.howstuffworks.com/pregnancy-and-parenting/pregnancy/fertility/sperm-bank.htm

University of Maryland Medical Center. Infertility in men. (n.d.). Retrieved from http://umm.edu/health/medical/reports/articles/infertility-in-men

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Questions for your Doctor

Before TC, many patients have not had much experience with doctors or specialists other than at regular exams or check-ups. With all these new words being thrown at you, it can be hard to know what is going on! It always helps to be as educated as possible on your situation, so we’ve prepared this list of questions to print and take with you to your doctors appointments. If a partner or friend accompanies you to your appointments, consider having her or him also fill out a Q/A chart to make sure you both interpreted what the doctor had to say correctly. Two sets of ears are better than one! And don’t be afraid to ask questions, no matter how silly they seem. The more open you are with the doctor, the better he can help with any concerns you are having.

Questions:
Where exactly is my cancer located?
Has it spread to other regions outside of the testicle?
What “stage” cancer do I have? What does that mean?
Do I have a seminoma or a non seminoma?
What is my prognosis?
How do I obtain a copy of my pathology reports? What do they mean?
What are my treatment options?
Will I lose a testicle?
Will I get a prosthesis?
What are the complications?
Should I consider sperm banking? Will treatment make me impotent?
What is the goal of treatment?
How long will treatment last?
What side effects are common with this treatment? Will I lose my hair?
Where are treatment centers located? How experienced are the doctors there?
Should I consider taking part in a clinical trial?
How likely is TC to come back after finishing treatment?
How do I find out what my insurance will cover?
How do I pay for what insurance doesn’t cover?
How will testicular cancer affect my everyday life? (Work, family, hobbies, etc.)
What risks are present?
Would it be helpful to get a second opinion?
How will my family be affected?
How should I tell my kids?
What changes should I make to my lifestyle? (diet, exercise, etc.)
How can I prepare for treatment? Should I eat before? Do I need to bring anything special?
How can you tell if treatment is working?
What if it isn’t working? What other options do I have?
In case of an off-hours emergency, who should I contact?
Is there anything I can’t do because of TC or treatment?
How many times a week should I expect to have doctors appointments?
Are mental health professionals available to talk with me about the psychological side effects of cancer? How do I contact them?

American cancer society. Questions to ask your doctor when you have cancer. (n.d.). Retrieved from http://www.cancer.org/treatment/findingandpayingfortreatment/treatmentdecisiontoolsandworksheets/questionstoaskyourdoctor/index

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Self Examination


EARLY DETECTION IS KEY!

Performing monthly testicular self-examinations is a quick and painless way to keep in tune with your testicular health and detect any changes!

How to Perform a Testicular Self-Examination

A testicular self-examination is most effective after a warm shower when the testes are relaxed.

1. Visually and manually check for swelling or heaviness.
2. Manually manipulate each testicle fully with both hands. Place your thumbs on the top of the testicle, with your index and middle fingers under the testicle you are examining. Roll the testicle around feeling for any lumps or abnormalities. This should not be painful.
3. Repeat the procedure on the other testicle. You should not be alarmed if the testicles are not identical in size as this is not uncommon. However, if you notice shrinkage or enlargement of one or both of the testicles in comparison to your last self-examination, you should seek medical attention.

Some men with testicular cancer have no symptoms at all, however the following list shows common signs of possible testicular cancer. Things to watch for are:


• Changes in the size of one or both testicles (swelling or shrinking)
• Lumps; Lumps may be painful or not painful at all, but any lumps or knots should be checked by a Physician
• Aches/Discomfort/Pain in the groin, scrotum or testicle
• Feeling of heaviness in the scrotum
• Lower back pain
• Lower abdominal aching
• Swelling, enlargement or tenderness of the breasts
• Sudden build up of fluid in the scrotum
• Shortness of breath and/or chest pain

If at any point you detect any of the signs or symptoms above, or anything else unusual, you should seek medical attention immediately. While if caught early, testicular cancer has one of the highest cure rates of all cancers, it is an aggressive cancer and can grow and spread rapidly. If embarrassment is a problem, just remember that this visit will give you peace of mind and possibly save your life!

Causes of Testicular Cancer:

Almost all testicular cancers begin in germ cells, or sex cells. A rogue cell will develop an abnormality. When the cell reproduces, the new cells also have the mutation. As uncontrolled cell growth continues to replicate, they form a mass, or lump. It is unclear what causes the abnormalities in germ cells to begin with.

Risk Factors for Testicular Cancer

Though the causes of testicular cancer are largely unknown, some risk factors have been linked to testicular cancer. (A risk factor is anything that increases the likelihood of developing a disease.) Still, most men diagnosed with testicular cancers have no known risk factors. Some Known Risk Factors Include: Personal history of testicular cancer: Men who have previously had testicular cancer are at increased risk to develop it in the other testicle. Age: Testicular cancer is most common among men aged 15-35, but men of all ages are vulnerable! Approximately 50% of the cases of testicular cancer occur in men between the ages of 20 and 34. Race: While there is no concrete data to explain why, Caucasian men have experienced a higher incidence testicular cancer than men of other races. Family history: Research shows men with a close family history of testicular cancer are at higher risk for developing testicular cancer then men with no family history. Medical history: Males born with an undescended testicle (cryptorchidism) are at increased risk of developing testicular cancer. Approximately 3% of males are born with this condition. One or both of the testicles do not descend from the abdomen into the scrotum prior to birth, as is normal. In many cases, the testicle will descend into the scrotum during the first year of life. If this does not happen, surgery may be needed to bring the undescended testicle out of the abdomen. A diagnosis of HIV or AIDS puts men at increased risk for developing testicular cancer, although for reasons unknown. Diseases causing abnormal testicular development will increase the likelihood of a man developing testicular cancer. If you have any of the warning signs or are experiencing any symptoms associated with testicular cancer, see your doctor right away. Also inform your physician if you have had a personal history, family history or medical history that may put you at increased risk.
http://www.cancer.org/cancer/testicularcancer/overviewguide/testicular-cancer-overview-what-causes
http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/about/testicular-cancer-risks-and-causes
http://www.mayoclinic.org/diseases-conditions/testicular-cancer/in-depth/CON-20043068
http://www.cancer.net/cancer-types/testicular-cancer/symptoms-and-signs

Download a PDF of this information.

Stages of Testicular Cancer

The stage of cancer diagnosis refers to the severity and aggressiveness of the cancer. A ranking will describe how far the cancer has spread and will help determine what treatment options may be best, as well as determining prognosis.
In addition to numeral rankings, the letters T, N, M, and S help further specify the intensity of the disease based on standards set by the American Joint Committee on Cancer. The TNM is the most useful and universal staging system used by physicians today.

The TNM System:

T: TUMOR- assesses the depth of the primary tumor and whether or not it has spread into tissues nearby to the testicle TX: it is not possible to measure the tumor T0: a tumor has not been found Tis: abnormal cells are found in situ—they are only found in the outermost layer of tissues and have not grown into deeper tissues (also called pre-cancer) T1, T2, T3, and T4: refer to the depth of the primary tumor and the various layers that is involved N: NODE- confirms if cancer has spread into lymph nodes near the testicle NX: it is not possible to evaluate the lymph nodes N0: cancer is not detected in nearby lymph nodes N1, N2, N3: extent to which cancer has invaded lymph nodes based on size and number of nodes involved M: METASTISIS- refers to spreading of the cancer to distant lymph nodes, organs, and other body parts MX: physicians are unable to evaluate metastasis M0: distant spread of cancer was not found M1: cancer has been detected in distant tissues or organs—meaning the cancer has spread to other body parts S: SERUM (not used in the TNM system) determines whether tumor markers that are created by some testicular cancers are present in the blood. Serum tumor markers unique to testicular cancer include alpha-fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH). Elevated levels of any of these markers may be suggestive of a germ cell tumor. Levels should be collected throughout your treatments and at follow ups to see if the tumor is responding to treatment or if relapse occurs. It is important to speak with your doctor regarding the ranking system—a different version exists for each type of cancer. Speaking with your physician will ensure you receive the correct information for testicular cancer and what it means for your diagnosis.

Numerical Staging:

Once physicians have assessed the T, N, and M values for a patient, the three values are combined to determine an overall stage from I-III (1-3). The stages increase in severity. A lower stage is associated with better prognosis. Stage 0 Also called carcinoma in situ Abnormal cells are present, but they have not become cancer or spread to neighboring regions Often called “precancerous” Stage I: The earliest stage Cancer has been detected, but has not spread out of the testicle into lymph or organs 1s indicates that serum levels are elevated after surgery Stage II: The cancer has spread into neighboring lymph nodes The letter assigned next to the stage number describes the size of the lymph node 2A: smaller than 2 cm 2B: 2-5 cm 2C: 1 or more (at least one) lymph node is bigger than 5cm Stage III: Cancer has metastasized to distant lymph nodes or any organ in the body 3A: cancer has been detected in the lungs or distant lymph nodes. Serum marker levels are normal or only slightly elevated 3B: cancer has metastasized to the lungs or distant lymph nodes. Serum marker levels are consistently moderate-high 3C: can be either or both of the following: cancer has spread to organs (other than the lung) formerly called stage 4 testicular cancer cancer has spread to one or more lymph nodes or organs and serum marker levels are very high Recurrent cancer: cancer that has returned after treatment. It will need to be re-staged and treated accordingly. Risk Assessment: 3 risk groups are identified based on level of tumor markers, sites of metastases and the origin of germ cell tumors. They are good risk, intermediate risk and poor risk. Treatment and cure varies depending on which group you are in.

Two Major Types of Staging:

1. Clinical Staging

• Clinical staging uses tumor biopsies, blood tests, physical examinations, CT scans, x-rays, and other imaging tests to estimate the extent/severity of a cancer. The clinical stage is important when deciding on treatment plans and also provides a good reference to see if treatment is working.

2. Pathologic Staging

• Pathologic staging (surgical staging) gives doctors a more accurate portrayal of the cancer’s presence in the body. Tissue samples from the body, taken out as part of treatment or just to see how much cancer is in area, give doctors more precise information about the cancer. This information is used in treatment decisions and in determining a prognosis. It can also be used to see if the treatment is working.

Additional Factors Affecting Stage Determination:

Grade: Grade refers to the differentiation of cells; that is, how abnormal they appear when examined under a microscope. Cells are given a “grade” from 1-4. The more abnormal the cell is, the higher the grade will be. A grade of 1 means cells resemble normal tissue. A grade of 4 means they are more distorted. Grading can be an important factor in deciding on a treatment plan because the more abnormal a cell looks, the quicker it grows or spreads. Tumor Marker Levels: Specific tumor markers found in the blood may indicate the presence of testicular cancer. The amount of this tumor marker in the blood can be considered when diagnosing. The tumor markers indicative of testicular cancer include AFP, hCG, and LDH. Cell Type: The type of cancer cell present can affect treatment regimes and prognosis. Most testicular cancer cells develop from germ cells, the cells that produce sperm. In rare cases, testicular cancer develops from stromal tumors.

The Two Types of Germ-Cell TC:

• Testicular cancer is divided into many subsets. The two most common are seminomas and nonseminomas, which account for the majority of TC cases. It is important to remember that these numbers are just averages and they can occur to any male at any age!

Seminomas: Classical seminomas: generally occur in men 30-50 years old Spermatocytic seminomas: typically seen in men over the age of 55 and are less common Non-seminomas: These are more common than seminomas and grow/spread more rapidly. Because of this, they are more difficult to cure. If seminoma and nonseminoma cancer cells are seen, the cancer will be diagnosed as nonseminoma overall because more aggressive treatment options will need to be used for this type of TC. They are usually seen in younger men (15-40) but can affect men of all ages. They are further subdivided based on the cell types. Choriocarcinoma: highest risk of metastasizing to other body regions but very rare Teratoma: lowest risk of metastasizing to other body regions Embryonal carcinoma: intermediate risk of metastasizing Yolk sac carcinoma: intermediate risk of metastasizing

Stromal tumors (not germ cell tumors): Stromal tumors are very rarely seen in adults (account for 1 in 20 testicular tumors seen in adults), but are more common in young boys (1 in 5). The tumor originates in the supportive tissue of the testicle, but typically is localized to the area and is not cancerous. In rare cases where cancerous stromal tumors are present and have spread, a poorer prognosis may be given because stromal tumors do not respond well to chemo or radiation. The two most common types of stromal tumors are Leydig cell tumors and Sertoli cell tumors.

Secondary Testicular Tumors
Cancers are named after the area they originate in. Secondary testicular tumors are not true testicular cancers because the cancer did not originate in the testicle. Secondary testicular tumors describe other cancers that have spread to the testicles. The tumors will be treated based off of the type of cancer it really is and prognosis will be dependent upon that as well.

http://www.cancer.org/cancer/testicularcancer/detailedguide/testicular-cancer-staging
http://www.cancer.gov/cancertopics/pdq/treatment/testicular/Patient/page2
http://www.cancer.org/treatment/understandingyourdiagnosis/staging
http://www.cancer.gov/cancertopics/pdq/treatment/testicular/Patient/page5

Above have been cited. Below have not been.
http://www.cancer.net/research-and-advocacy/asco-care-and-treatment-recommendations-patients/tumor-markers-testicular-cancer-and-extragonadal-germ-cell-tumors-teenage-boys-and-men
http://www.cancer.net/cancer-types/testicular-cancer
http://www.cancer.org/cancer/testicularcancer/detailedguide/testicular-cancer-treating-by-stage
http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/treatment/testicular-cancer-stages
http://www.cancer.net/cancer-types/testicular-cancer/stages
http://www.cancer.gov/cancertopics/factsheet/Detection/staging
http://www.cancer.net/research-and-advocacy/asco-care-and-treatment-recommendations-patients/tumor-markers-testicular-cancer-and-extragonadal-germ-cell-tumors-teenage-boys-and-men
http://www.tc-cancer.com/about/nonseminoma.html
http://www.cancer.org/cancer/testicularcancer/overviewguide/testicular-cancer-overview-what-is-testicular-cancer

Download a PDF of this information.

Signs and Symptoms of Testicular Cancer

EARLY DETECTION IS KEY!
The self exam is quick, painless, and should be done once a month.
Look for:
-changes in size (swelling or shrinking of the testes)
-lumps (can be painful or not painful at all)
-aches/discomfort/pain in the groin, scrotum or testicle
-feeling of heaviness in the scrotum
-lower back pain
-swelling or enlargement of breasts or tenderness
-sudden buildup of fluid in the scrotum
-shortness of breath and/or chest pain
…as all could be symptoms of cancer.
However, these symptoms do not mean you have cancer.
Go to a doctor as soon as possible to be properly diagnosed if any of these persist and progresses

Some men may have no symptoms at all.

Causes of Testicular Cancer: Who is Vulnerable?

Almost all testicular cancers begins in germ cells. A cell will develop an abnormality. When the cell reproduces, the new cells also have the mutation. This group of cells with uncontrolled growth continue to replicate and may form a mass, or lump. It is unknown what causes the abnormalities in germ cells. Though the causes of testicular cancer are largely unknown some risk factors have been linked with testicular cancer. Still, most men diagnosed with testicular cancers do not have any known risk factors. A risk factor is anything that increases the likelihood of developing a disease.

Personal history of testicular cancer:

Men who have previously had testicular cancer are at increased risk to develop it in the other testicle. Age: Testicular cancer is most common among men aged 15-35, but all men of all ages are vulnerable! Approximately 50% of the cases of testicular cancer occur in men between the ages of 20 and 34. Race: Though data does not explain why, data does show that white men are more likely to get testicular cancer than men of other races. Family history: Research shows men with a family history of testicular cancer are more at risk, though rarely do men diagnosed have any family history of the cancer. Medical history: Males born with an undescended testicle are at increased risk. Approximately 3% of males are born with this condition. One or both of the testicles did not descend from the abdomen into the scrotum before birth, as is normal. In many cases, the testicle will descend into the scrotum during the first year of life. If this does not happen, surgery may be needed to bring the undescended testicle out of the abdomen. Though not understood why, diagnosis of HIV or AIDS puts the man at increased risk for developing testicular cancer. Diseases which cause abnormal testicular development increase the likelihood of a man developing TC. Talk to your doctor about anything out of the ordinary—better to be safe than sorry. Even if it is embarrassing, it will allow you peace of mind.

http://www.cancer.org/cancer/testicularcancer/overviewguide/testicular-cancer-overview-what-causes
http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/about/testicular-cancer-risks-and-causes http://www.mayoclinic.org/diseases-conditions/testicular-cancer/in-depth/CON-20043068
http://www.cancer.net/cancer-types/testicular-cancer/symptoms-and-signs

Download a PDF of this information.

Testicular Cancer Spreading Patterns

Testicular cancer starts in the testicle and generally follows a predictable pattern of spreading ”north.”

Testicle (Origin Site) >> Lymph Nodes >> Lungs >> Brain/Liver/Other Regions

Latest Research on Testicular Cancer

Research on testicular cancer is ongoing at many hospitals, medical centers, universities and clinics across the globe.  Doctors, scientists and researchers are continuously looking for causes, prevention, improved treatment methods, and ways to detect testicular cancer sooner.  A lot of new information about testicular cancer and treatment options comes from clinical trials.

Here’s a brief summary of what the latest research has found:

• Genetics:
  Cancer results from a mutation in cells.  Researchers think that the cell damage that results in testicular cancer occurs when the male is at a very young age.  Scientists have identified several gene variants that may increase the risk of a male developing testicular cancer.  Identifying genes related to testicular cancer may one day be helpful in early detection or determining likelihood of reoccurrence but for now, the area still needs a lot of study.
• Treatment:
  Using the findings from clinical trials, scientists have found factors that help predict how one will respond to treatment.  This can help doctors determine how vigorous of treatment methods one would need.  For example, if the factors indicate that a patient will have a good prognosis, the doctor may be less likely to recommend high doses of radiation therapy or chemo.  If factors predict that the patient will not respond well to treatment, more intense treatment may be recommended.  Other research hopes to improve treatment options by inventing new methods or by improving existing methods.  Scientists are trying to find if new drugs or drug combinations could help treat TC or lessen side effects.
• Fertility Concerns
  Fertility after testicular cancer can be a huge concern for many men battling TC.  Although removal of a single testicle does not make a man impotent, some men have cancer in both testicles and need to have them both removed.  In this case, the man would become infertile.  Research continues to address this issue and has resulted in improved storing of sperm for later use and in assisted reproduction methods.  This allows for a man to father children even if he undergoes a double orchiectomy or has a low sperm count.
• Quality of Life
  Research is being done to determine what factors influence your experience with cancer.  Studies are being conducted to see how counseling, social support, religion, and other factors may improve one’s well-being.  Other research focuses on how to manage side effects, which also plays a large role in quality of life.
• Remission
  Research is being done to determine how often men should come in for check-ups after they have completed treatment and are cancer-free.  It is important for men to come in for follow up visits because if the cancer has returned, it is most curable if found right away.  Data shows that many men do not continue with check-up appointments.  Researchers are currently investigating what factors may be responsible for this.
• Stem Cell Transplant
  For patients with very aggressive or advanced cancer, a stem cell transplant can serve as a source of hope, though it is not without risk.  High-dose chemotherapy would be needed to kill especially aggressive cancers, but such high doses would also kill healthy cells.  During the stem cell transplant procedure, the patient is initially given drugs to drive the stem cells out of the bone marrow. Once the cells have entered into the blood, they are collected and stored outside of the body.  The patient is then given high-dose chemotherapy, as much as 5 times the usual dose.  The stored stem cells are infused back into the patient to compensate for the cells killed during the chemo.  After a few weeks, the procedure is repeated. This new approach offers hope to advanced stage TC patients and is usually reserved for patients whose cancer has returned after previous treatments.  Out of the patients undergoing the study who were deemed “incurable,” 25% were cured following this new treatment.  Though the procedure offers hope, it comes with risks as well.  The toxicity window is very small.  Too little dosage may be ineffective, while too much can be fatal.  It is important that you fully understand the risks and benefits of stem cell transplants and should you decide to undergo the procedure, look for an experienced doctor.   Stem cell transplants can be very expensive.  Check with your insurance to see what they cover and to see how much your co-pays will amount to.

• http://www.cancer.org/cancer/testicularcancer/detailedguide/testicular-cancer-new-research
• http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/treatment/whats-new-in-testicular-cancer-research
• http://www.cancer.org/cancer/testicularcancer/detailedguide/testicular-cancer-treating-high-dose-chemo-stem-cell
• http://www.webmd.com/cancer/news/20070725/testicular-cancer-second-chance

Nutrition

As we’ve heard time and time again, good nutrition is an important component to healthy living. While there is no direct evidence linking diet to testicular cancer (or to providing a cure), proper nutrition can play a crucial role in coping with both the side effects of the cancer itself, as well as the side effects associated with common treatment regimens.  Good nutrition also promotes better overall health, and will help to rejuvenate, reproduce and rebuild healthy cells during treatment.

Nutrition During Treatment
Adequate nutrition throughout treatment is key to maintaining a treatment regimen and preventing treatment interruption. Gastrointestinal upset can be linked to both the disease itself and/or result from the treatment. GI upset may cause loss of appetite, weight loss, diarrhea, stomach pain, fatigue, etc.; testicular cancer patients commonly experience these GI issues. Nausea is an issue that often arises during treatment. Nausea and a persistent absence of appetite can quickly lead to malnutrition and weight loss. If loss of appetite is an issue, smaller, more frequent meals throughout the day may be more favorable than a few large meals. Some food recommendations include peanut butter, whole grains, lean meats, vegetables, nuts, and fruits. Some patients have found that eating cold, plain foods, prior to or following a treatment session, can make the food easier to swallow and keep down. A dietician may recommend a healthy caloric intake goal for the testicular cancer patient. They may also recommend foods that may lessen GI upset or may suggest alternative nutrition options.

If nutritional needs cannot be maintained by eating, a health care professional will work with the patient to determine if a supplemental food source is necessary.  Such alternatives include the Total Parenteral Nutrition, or TPN.  TPN is made up of proteins, carbohydrates, electrolytes, sugar, and lipids and is specially formulated based on the patient’s individual nutritional needs. TPN is administered through a needle or catheter and patients may receive TPN as often as prescribed.

Nutritional therapy is an emerging field and testicular cancer patients are encouraged to meet with such professionals should weight loss and/or nutritional issues arise.

Benefits of Maintaining a Proper Diet:

• Provides the energy necessary for maximum strength and optimal health while undergoing treatment
• Maintain a healthy weight
• Ensures delivery of necessary vitamins and nutrients
• Increases the body’s ability to tolerate side effects from chemotherapy, radiation, surgery, etc.
• Reduces the likelihood of getting an infection/increases ability to fight off infection should one develop
• Promotes a quicker and healthier recovery

What Does a Good Diet for a Testicular Cancer Patient Consist of?
Like anyone else’s diet, a testicular cancer patient’s diet should consist of carbohydrates, some fats, minerals, vitamins, proteins, and water. While these necessities may come in various forms, some sources are better choices than others. It is important to make good choices. Here are some suggestions:

• Protein:
  • Lean meats: beef, pork, ham, veal, etc.
    • Avoid processed meats to reduce sodium intake; choose lean or low fat meats instead
  • Poultry: chicken, duck, turkey, etc.
    • Avoid processed poultry and chicken with skin or breading; choose healthier cooking options – – grilled over fried
  • Seafood: salmon, tuna, shrimp, flounder, etc.
  • Nuts: cashews, almonds, pistachios, pecans, peanut butter, etc.
  • Dairy: eggs, reduced fat milk, Greek yogurt, cheese, etc.
  • Beans:  chick peas, lima beans, kidney beans, soy beans, pinto beans, etc.
  • Soy products: tofu, veggie burgers, edamame
• Carbohydrates:
  • Choose whole grain products over refined grains
    • Wheat, oats, rice
  • Starchy vegetables and beans
    • Sweet potatoes, yams, corn, green peas
  • Fruit
    • Fresh fruit is a healthier option than fruit juice
    • Bananas, berries, etc.
  • Milk
• Fats:
  • Choose unsaturated fats
    • Trans fats and saturated fats will raise cholesterol to unhealthy levels and increase your chance for cardiovascular disease
    • “Good” fats: olive oil, canola oil, avocados, olives, nuts, peanut butter, soymilk, walnuts, salmon, etc.
    • Incorporate omega-3 into your daily diet
      • Sources include fish, canola oil, walnuts
  • Vitamins:
    • Vitamin A: important for healthy immune system, vision, skin, and cell growth & development
      • Milk, eggs, green vegetables, orange fruits, etc.
    • Vitamin B (B12, B6, B1, B3, B2, B9): all B vitamins have different functions—collectively they: play a role in producing red blood cells, maintain healthy skin, support proper nerve/heart/muscle/brain functioning
    • Vitamin C: needed to form collagen; important for healthy teeth, bones, and gums Vitamin C helps promote wound healing and brain functioning.
      • Broccoli, spinach, kiwi, strawberries, citrus fruits, tomatoes
    • Vitamin D: helps the body absorb calcium, resulting in stronger bones
      • The body will manufacture vitamin D from sunlight
      • Egg yolks, salmon, tuna, orange juice, milk
    • Vitamin E: important for red blood cell health; protects cells from damage
      • Vegetable oils, nuts, whole grains, spinach

Easy Ways to up Your Caloric Intake
Many patients experience loss of appetite, nausea and/or other conditions, which can result in weight loss. It is important to maintain a healthy weight. Consider these ways to add extra calories to your diet:

• Increase your protein intake
  • Add hard boiled eggs or any left over meat to soup, salad or other dishes
• Increase your dairy intake
  • Drink whole milk; the extra calories and fat can help boost weight gain
  • Add cheese to meals such as eggs or casseroles
  • Add whipped cream to fruits or sweets
• Increase butter consumption
  • Butter is high in calories and can be added to many foods
• For added calories, consider sweets (How often is someone going to tell you that? Go for it!)
  • Add jam to bread
  • Ice cream, cake, etc.
• Don’t choose “low-fat” or “non-fat” options
  • Choose full fat options when choosing condiments, dressings, yogurts, mayonnaise

Radiation
If your treatment regimen consists of radiation, you may develop a sore mouth and have trouble swallowing. This can affect your nutritional intake as eating may be painful, and one may want to avoid it.

Here are some foods that are easy on a sore mouth and will help a patient meet their necessary caloric intake level:

• Soups and pastas
• Protein shakes
• Macaroni and cheese
• Applesauce
• Yogurt
• Pudding
• Oatmeal
• Bananas
• Jell-O
• An additional option would be to puree other foods to make them easier to swallow

Chemotherapy and Nausea
One of the most common side effects of most chemotherapy regimens is nausea. Helpful hints to battle nausea are to choose bland, odorless foods that would not upset the stomach. Some preferable choices might be:

• Crackers
• Rice
• Potatoes
• Noodles

Important Food Safety Fact!

Because cancer patients have a weaker immune system, it is imperative to practice safe cooking habits; avoid raw foods, wash hands thoroughly, avoid contaminated surfaces, cook meat entirely, and always wash fruits and vegetables.

The Importance of Proper Nutrition Post-Cancer
While proper nutrition has not been shown to prevent cancer or reoccurrences, it can help one develop a healthy lifestyle after cancer. Adopting healthy eating habits is important to maintaining a general overall weight and
well-being.

References Cited

• http://www.helpguide.org/life/healthy_diet_fats.htm
• http://www.choosemyplate.gov/food-groups/grains.html
• http://www.everydayhealth.com/testicular-cancer/diet-for-patients.aspx
• http://www.helpguide.org/life/healthy_diet_fats.htm
• http://www.choosemyplate.gov/food-groups/grains.html
• http://www.everydayhealth.com/testicular-cancer/diet-for-patients.aspx
• http://www.everydayhealth.com/testicular-cancer/diet-for-patients.aspx
• http://www.choosemyplate.gov/food-groups/dairy.html
• http://kidshealth.org/teen/misc/vitamin_chart.html

More on Nutrition

During Treatment

• Adequate nutrition is essential to maintaining a treatment plan and preventing treatment interruption. Gastrointestinal upset and resulting symptoms (nausea, weight loss, diarrhea, loss of appetite, stomach pain, fatigue, etc.) are commonly experienced by testicular cancer patients. A persistent loss of appetite can quickly lead to malnutrition and weight loss. A dietician can provide recommendations on a healthy caloric intake level, what types of foods may lessen GI upset, or may suggest alternative nutrition options.
• As the body weakens from fighting cancer, food can provide much-needed extra energy. If appetite loss is an issue, small meals throughout the day may be more favorable than the standard three large meals. Recommended foods for patients dealing with loss of appetite include peanut butter, whole grains, lean meats, vegetables, nuts, and fruits. Some men have reported that cold, plain foods are easier for them to swallow and keep down.
• If nutrition is unable to be maintained through eating, a health care professional will work with the patient to determine if a supplemental food source is necessary. Such alternatives include the total parenteral nutrition, or TPN. TPN is made up of proteins, carbohydrates, electrolytes, sugar, and lipids. It is administered through a needle or catheter. Patients should receive this supplemental nutrition source as little or as often as prescribed.
• Testicular cancer patients are encouraged to meet with nutrition therapists or food specialists should weight loss and/or nutritional issues arise.

Nutrition in life after cancer

• While proper nutrition has not been shown to prevent cancer from occurring or reoccurring, it can help one develop a healthy lifestyle after cancer. Adopting healthy habits is important to maintaining a healthy weight and one’s overall well-being.

Maintaining a proper diet can:

• Provide much-needed energy to the patient
• Help maintain a healthy weight
• Ensure adequate intake of necessary vitamins and nutrients
• Increase one’s ability to tolerate side-effects from chemo, radiation, surgery, etc.
• Reduce the likelihood of getting an infection/increase ability to fight off an infection
• Promote a quicker recovery

What does a good diet for a testicular cancer patient consist of?

• Like anyone else’s diet, a TC patient’s diet should consist of carbohydrates, vitamins, proteins, some fats, and water
• Some foods are better sources for these essential nutrients than others
• It is important to chose from “good” sources because they provide the following:
• Protein:
  • lean meats: beef, pork, ham, veal, etc.
    • try to avoid processed meats because they are high in sodium
  • fish
  • poultry: chicken, duck, turkey, etc.
    • try to avoid processed poultry and chicken with skin or breading
    • choose healthier cooking options like grilled over fried
  • nuts: cashews, almonds, pistachios, pecans, peanut butter, etc.
  • dairy: eggs, reduced fat milk, Greek yogurt, cheese, etc.
  • beans:  chickpeas, lima beans, kidney beans, soy beans, pinto beans, etc.
  • soy products: tofu, veggie burgers, edamame
  • seafood: salmon, tuna, shrimp, flounder, etc.
• Carbohydrates:
  • Choose whole grain products over refined grains
    • Wheat, oats, rice
  • Starchy vegetables and beans
    • Sweet potatoes, yams, corn, green peas
  • Fruit
    • Fresh fruit is a healthier option than fruit juice
    • Bananas, berries, etc.
  • Milk
• Fats:
  • Choose unsaturated fats
    • transfats and saturated fats can raise cholesterol to unhealthy levels and increase your chance for cardiovascular disease
    • “good” fats include: olive oil, canola oil, avocados, olives, nuts, peanut butter, soymilk, walnuts, salmon, etc.
    • try to incorporate omega-3 into your daily diet
      • sources include fish, canola oil, walnuts, etc.
      • Vitamins:
        • Vitamin A: important for healthy immune system, vision, skin, and cell growth & development
      • Milk, eggs, green vegetables, orange fruits, etc.
      • Vitamin B (B12, B6, B1, B3, B2, B9): all B vitamins have different functions. Collectively they play a role in producing red blood cells, maintaining healthy skin, and supporting proper nerve, heart, muscle, and brain functioning.
    • Vitamin C: needed to form collagen. It is important for healthy teeth, bones, and gums.  Vitamin C helps promote wound healing and brain functioning.
      • Broccoli, spinach, kiwi, strawberries, citrus fruits, tomatoes
    • Vitamin D: helps the body absorb calcium, resulting in stronger bones.
      • Body will manufacture Vitamin D from sunlight
      • Foods containing Vitamin D include: egg yolks, salmon, tuna, orange juice, milk
    • Vitamin E: important for red blood cell health and protects cells from damage.
      • Vegetable oils, nuts, whole grains, spinach

If you find yourself losing an unhealthy amount of weight, try these ways of adding extra calories to your diet:

• Increasing your protein intake by:
  • Adding hard boiled eggs or meat to soup, salad, or other dishes
• Increasing your dairy intake by:
  • Drink whole milk (the extra calories and fat can help boost weight gain)
  • Add cheese to meals such as eggs or casseroles
  • Add whipped cream (remember, more calories!)
• Increase butter consumption
  • Butter is high in calories and can be added to many foods
• For additional calories, consider sweets
  • Add jam to bread
  • Ice cream, cake, etc.
• Don’t choose “low-fat” or “non-fat” options
  • Choose full fat options when choosing condiments, dressings, yogurts, mayonnaise, etc.

Some patients undergoing radiation report mouth sores and oral or throat pain. Here are some foods that may prevent additional pain caused by eating:

• Soups and pastas
• Protein shakes
• Macaroni and cheese
• Applesauce
• Yogurt
• Pudding
• Oatmeal
• Bananas
• Jello
• Or try pureeing foods so that they are easier to swallow

If experiencing nausea, bland odorless foods may be easier to keep down. Examples include:

• Crackers
• Rice
• Potatoes
• noodles

Remember to always wash fruits and vegetables and make sure meats are fully cooked. Wash your hands as often as necessary. Cancer patients have weakened immune systems and some food contaminants could make you very sick!

References Cited

• http://www.helpguide.org/life/healthy_diet_fats.htm
• http://www.choosemyplate.gov/food-groups/grains.html
• http://www.everydayhealth.com/testicular-cancer/diet-for-patients.aspx
• http://www.everydayhealth.com/testicular-cancer/diet-for-patients.aspx
• http://www.choosemyplate.gov/food-groups/dairy.html
• http://kidshealth.org/teen/misc/vitamin_chart.html

Coping with the Financial “Side Effects” of Testicular Cancer

Your doctor will frequently go over the physical side effects of cancer, but an area that often gets neglected in discussion—though it makes a huge impact on your life—is the costs associated with cancer treatment.  Even if you have insurance, copays and medication costs can quickly add up.  Many men feel like they need to continue working during treatment to be able to avoid debt.  Some men do find themselves able to balance both work and treatment, but the main concern should be getting better.  It may require doing research and talking to lots of people, but there are resources out there to help you cover the costs of cancer.

Cancer is not a disease that you can wait to treat.  Some men say they want to wait to get treatment until they can afford it, but postponing treatment can be detrimental.  Seek out resources that exist for people like you.

Resources:

For Children:
-If you are under the age of 18 and meet the eligibility requirements, you may want to talk to your doctor about St. Jude Children’s Research Hospital.  To qualify you must meet the eligibility requirements of a study they are currently conducting and should not have had treatment at another facility prior to acceptance, though some exceptions are made to this rule.  St. Jude will cover all costs for treatment not covered by insurance (and entire cost of treatment if uninsured) and may help compensate for travel and living expenses.

Government Programs:
-Federal and state programs exist to provide assistance to cancer patients and their families.  They usually are set up for low-income families, the elderly, and the disabled.  Programs include:
-Medicaid and Medicare 800-633-4227, www.cms.gov
-Social Security Administration 800-772-1213, www.ssa.gov
-US Department of Health and Human Services, www.hhs.gov

Pharmaceutical Assistance Programs  
-Check with your drug manufacturer to see if they have a patient assistance program.  These programs help patients pay for the medications they need.
-Partnership for Prescription Assistance, (888-477-2669), www.pparx.org

The Cancer Financial Assistance Coalition (CFAC)
-CFAC is composed of 14 member organizations, all dedicated to reducing financial challenges experienced by cancer patients.  On their website, you can search by diagnosis or by the type of resource that you are in need of.  Resources include general living expenses, housing, medical expenses, prescription assistance, scholarships, supplies, insurance and transportation. www.cancerfac.org

Other Cancer Organizations

• American Cancer Society, 800-ACS-2345, www.cancer.org
• CancerCare, 800-813-HOPE(4673), www.cancercare.org
• Cancer.net, Cancer.net offers a full page dedicated to financial resources. http://www.cancer.net/navigating-cancer-care/financial-considerations/financial-resources
• Testicular Cancer Awareness foundation – If you meet the eligibility requirements, you can apply for assistance from TCAF.  If approved, TCAF may assist with costs such as your mortgage, groceries, or gas.
  http://www.testicularcancerawarenessfoundation.org/financial-assistance/
• Livestrong Foundation – The Livestrong Foundation offers multiple resources on their website, with a special page designated to financial assistance. http://www.livestrong.org/we-can-help/insurance-and-financial-assistance/

Other Organizations

• United Way, www.unitedway.org
• Religious center,churches, charities, etc.
• local programs
• See if your community offers any programs to help cancer patients.  Some community organizations offer help with rides to appointments and may even help your family with meals.

References Cited

• http://www.stjude.org/stjude/v/index.jsp?vgnextoid=a738588865e70110VgnVCM1000001e0215acRCRD
• http://www.cancercare.org/publications/62-sources_of_financial_assistance
• http://money.usnews.com/money/personal-finance/articles/2014/02/10/how-to-pay-for-cancer-treatment-when-youre-broke
• http://www.cancer.org/treatment/findingandpayingfortreatment/understandingfinancialandlegalmatters/index
• http://www.testicularcancerawarenessfoundation.org/financial-assistance/
• http://www.livestrong.org/we-can-help/insurance-and-financial-assistance/
• www.unitedway.org
• http://www.cancer.net/navigating-cancer-care/financial-considerations/financial-resources
• www.cancercare.org
• www.cancer.org
• http://www.cancerfac.org/
• www.pparx.org
• www.hhs.gov
• www.ssa.gov
• www.cms.gov

How will testicular cancer affect my sex life?

Many patients fear that having testicular cancer means that they can’t have sex anymore or that their sex life will be permanently altered.  Never be uncomfortable to discuss this with your doctor! He is there to help, NOT to judge, and has likely had experience with many patients going through the same thing.  Sex therapists may be an additional option to pursue if your doctor can’t address all your concerns. But remember, a doctor can’t treat something that he doesn’t know about, so be open and honest about ALL of your concerns.

Here are a few things to keep in mind. Generally,

• Having one testicle removed will NOT decrease your fertility, sex drive, or performance. Your body will naturally compensate for the missing testicle by producing more testosterone and sperm in the remaining testicle.
• If cancer is found in both testicles, both will need to be removed. Your doctor will help create a testosterone supplement plan which will give your body the testosterone it needs, but can no longer make in high enough quantities once the testicles are removed.
• Following an inguinal orchiectomy, it is advised to wait a few weeks before trying to have sex.
• Being diagnosed with cancer is an emotionally, mentally, financially, and physically draining ordeal. Negative emotions can decrease your libido. Many patients find that once they come to terms with their diagnosis, their sex drive returns to normal.
• Following treatment sessions, you may experience side effects, such as fatigue. This extreme tiredness can decrease your libido and you may find that you want sex less often. This should be temporary and is completely normal!
• Not much research has been done on how chemotherapy is transmitted through semen. It is recommended to wear a condom to protect your partner from any potential risks.
• Radiation and chemotherapy may temporarily damage sperm. For this reason, it is advised to use protection to prevent pregnancy for a few months after treatment.
• If you undergo retroperitoneal lymph node dissection surgery and retrograde ejaculation occurs (when sperm doesn’t exit the body through the urethra, but instead ends up in the bladder), it may take a while to adjust, as you will no longer ejaculate as before.
• Like all things, everyone is affected differently. Some men report having no change in their sex life whatsoever, while others have needed hormone supplements to return their libido to normal. Talk to your doctor about YOUR unique situation.
• After treatment has ended, your sex life should completely return to normal. The risk of having a baby with abnormalities does NOT increase as a result of testicular cancer or treatment.
• It may go without saying, but cancer cannot be transmitted through intercourse. Some men are concerned about this, but there is nothing to be worried about!

References Cited

• Cancer Research UK. Fertility – having children after testicular cancer. (n.d.). Retrieved from http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/living/fertility-having-children-after-testicular-cancer
• Cancer Research UK.  Your sex life and testicular cancer. (n.d.). Retrieved from http://www.cancerresearchuk.org/cancer-help/type/testicular-cancer/living/your-sex-life-and-testicular-cancer
• The Testicular Cancer Resource Center. Testicular cancer and sex. (2012, December 5). Retrieved from http://tcrc.acor.org/tcsex.html

Treatment Options

Q: When is surgery appropriate?
A: for almost ALL testicular cancers, usually surgery is the first treatment option, -especially effective for early stage diagnoses.

Q: What is surgery for Testicular Cancer?
A: Diagnosis will determine the extent of the procedures needed.  Almost all testicular cancer patients will undergo an inguinal orchiectomy.

Q: What is Inguinal Orchiectomy?
A:

• first treatment attempt for almost all TC
• a surgeon will make a small incision by the bikini line and push the testicle up through the opening—no incision is ever made to the scrotal sac
• trying to remove cancer in the testicle without removing the testicle itself is done by very few surgeons and is not recommended (most surgeons will not even attempt this procedure because of risks)
• precancerous cells would likely be left behind which would result in cancerous cells developing again later
• this would also allow for the potential for cancerous cells contained in the testicle to become dislodged and travel to other areas of the body
• removing cancer without removing the testicle would require an incision in the scrotum.  This disrupts the body’s natural drainage system and would create a pathway for cancer to spread to other regions, making it more difficult to detect and treat.
• the procedure takes around 45 mins to an hour.
• some men stay in the hospital for a night to make sure
• everything is normal while some choose to go home the same day.  It’s a personal choice—either way, make sure pain killers are available to you if needed!
• following surgery, doctors will encourage you to get up and walk around a little but definitely do not overdo it with exercise or heavy lifting until cleared!
• some men come out of surgery with minimal pain, others report more
• some men opt for a prosthetic testicle to maintain the natural look and feel
• many men report soreness/pain/numbness at the site of the incision.  Wear comfortable clothes (i.e. sweat pants) to avoid agitating the area and causing additional discomfort

Q: What are the side effects of surgical inguinal orchiectomy?
A:

• as with any surgery, the risk of reacting negatively to anesthesia exists,general anesthesia and an epidural are offered as choices
• every surgery runs the risk of complications though the risk is relatively low for these surgeries
• no special expertise is required by the surgeon; this is a simple procedure but it still may be in your best interest to find a surgeon who has done this procedure many times before
• as long as the man has one healthy testicle remaining, sex drive, functioning, and fertility should not be affected long term.
• if problems in these areas exist before the surgery, they may be increased following an inguinal orchiectomy
• if both testicles are removed, the man will be unable to produce sperm and thus become infertile.  Testosterone supplements will be needed to maintain the testosterone levels in your body.

Q: What is Retroperitoneal Lymph Node Dissection (RPLND)?
A:

• it is difficult to determine whether the lymph nodes in the abdomen contain cancerous cells unless the lymph nodes are removed
• this procedure removes potentially cancerous cells and also aids in diagnosing the progression of the cancer
• it is sometimes done at the same time as the inguinal orchiectomy or can be done as a second procedure
• it is much more complex and lengthy operation (46 hours or more) than inguinal orchiectomy; seek a surgeon with experience
• RPLND involves a large incision along the abdomen through which the lymph nodes are removed
• an alternative to this open type of surgery is laparoscopic surgery
• a laparoscope is used to allow surgeons to see inside of the abdomen without physically placing their hands in the region; this allows for much smaller incisions. Multiple small incisions are made.  The laparoscope is inserted into the incisions to give the doctor a visual.  Other surgical tools are then used to remove the lymph.
• the effectiveness of this alternative is still being studied; many doctors feel open surgery is more successful in removing all of the lymph node
• if cancer is found in the lymph nodes removed via laparoscopic surgery, a second treatment option (chemo or radiation) is likely to be recommended since laparoscopic surgery is not thought to be as effective as open RPLND
• patients report a much easier recovery following laparoscopy than RPLND

Q: What are the side effects of RPLND Surgery?

• Although RPLND is a major surgery and serious complications can happen, they are not common
• all surgeries pose risks; same is true for this procedure.
• potential reactions to anesthetics
• less than 10% of men report temporary complications following surgery—these complications could arise with any surgery—and include bowel obstruction, infection at the site of incision, soreness/pain at the site of incision
• movement will be limited following surgery as the body takes time to heal; you won’t be able to get up and walk around too much
• The surgery itself does not cause impotence, but nerve damage sometimes occurs during RPLND to the nerves that control ejaculation, which can result in retrograde ejaculation.  This means that instead of semen traveling through the urethra and out of the body, the semen travels backwards and ends up in the bladder.  Nerve-sparing surgery preserves normal ejaculation functioning and has a high success rate.  Some men planning to have kids will collect and store sperm ahead of time just in case.
• Especially if you plan to have kids, it is important to find a surgeon with a lot of experience with nerve-sparing surgery to help ensure that retrograde ejaculation does not occur.
• Even if retrograde ejaculation occurs, most men do not have problems getting an erection or enjoying sex.
• Recovery from laparoscopic surgery is easier and shorter than RPLND (remember several small incisions instead of one larger incision)

Q: What about Chemotherapy  “Chemo”
A:

• Not all cancer is the same.  Your doctor will create an individualized treatment planned based off of your unique situation and what is best for you.  This will determine the dosage and frequency of your chemo treatments.
• Chemotherapy is the use of chemical substances or anticancer drugs.
• Chemo is not used if cancer is contained to the testes.  Rather, it is more commonly used if the cancer has spread out of the origin site to lymph nodes, tissues, or organs.
• Chemotherapy can be delivered in a variety of ways:
  • pills
  • IVs (through the veins) (most common administration method for testicular cancer)
  • intramuscular injections

Q: What are the uses of chemotherapy?
A:

• main treatment option aimed at destroying cancerous cells
• shrinking a tumor prior to using another treatment method
• following another treatment method to destroy any remaining cancer cells if present
• In advanced cancers, chemo is used to prolong life or to reduce symptoms
• The chemicals in the chemotherapy drugs travel throughout your whole body—this means they can target cancer cells that have spread out of the testes to other regions of the body.
• Chemo is delivered in cycles, meaning you will have a treatment period, followed by a rest period to allow the body to recover from the strong chemicals.  A cycle typically lasts 3 weeks to a month.
• Multiple chemotherapy drugs offer increased efficacy.  2 or more anticancer drugs are often used during a single chemotherapy session.

Q: What are the Side effects of chemo?
A:

• Chemotherapy is used to target cancer cells, but it can destroy healthy cells as well, creating undesirable side effects.
• Side effects differ depending upon the dosage and length of chemo cycles.
• Side effects experienced and severity differ greatly among patients.
• Side effects include:
  • dry mouth
  • hair loss
  • mouth sores
  • nausea/fatigue/vomiting
  • diarrhea
  • easy bruising and bleeding
  • increased risk of infection (chemotherapy kills off some white blood cells)
  • loss of appetite and subsequent weight loss
  • anemia
  • fluid retention
  • skin rash
  • digestive system problems
  • numbness/tingling in hands or feet
  • constipation

How to cope with chemotherapy side effects

• hair loss: hair loss can affect your self image.  Many patients opt for a wig or head covering.  Check with your insurance to see if a wig is covered.  Some patients prefer to buy a wig before all of their hair falls out to better match the wig to their natural hair color and to be better prepared for the emotions that accompany hair loss.  Hair will begin to grow back once treatment ends.  It may come back a different color or texture, but these changes are normally temporary.
• constipation: eat a diet rich in fiber, stay hydrated and exercise lightly when possible.  Stool softeners are often insufficient in treating constipation caused by cancer medications.  Talk with your doctor about laxatives.  They will help develop a balanced laxative schedule that works for you.
• diarrhea: stay hydrated and choose a healthy diet.  Talk with your doctor if diarrhea persists.  Some medicines, even over the counter, can interfere with your cancer drugs so it is best to have your doctor tell you what to take or avoid.
• infections: because chemo can destroy your cells that help fight infection, you are at an increased risk.  Maintain proper hygiene, wash hands regularly, and avoid unsanitary places to reduce your risk of acquiring an infection.  If you do get an infection, talk with your doctor to see if antibiotics are necessary.
• mouth sores/oral pain: maintain good oral health and choose a toothbrush with soft bristles to minimize pain from brushing.  Drink plenty of fluids. Gargling with salt water or switching toothpastes (ask your doctor which brands may help reduce irritation) may help.  If oral pain persists, ask your doctor about options.  He may recommend an over-the-counter pain killer such as ibuprofen or acetaminophen, or may prescribe something stronger like opiates.  Many patients report temporary relief from popsicles or ice chips.
• fatigue: Talk to your doctor if you experience fatigue as anemia (low red blood cell count) may be one of the causes, but is treatable.  Other causes of fatigue include the cancer itself, the treatment, or depression associated with the diagnosis.  If possible, try to do some light exercise or modified versions of your favorite activities.  Take short naps or breaks throughout the day and ask friends/family for help when you need it.  Make an effort to do some of the things you enjoy most.
• Nausea and vomiting: avoid foods with strong smells and fatty/greasy foods.  Many patients find that eating cold foods helps reduce nausea associated with food aromas.  Avoid binge eating and try smaller meals throughout the day instead of three large meals.  Eat slowly and don’t overeat.  If the nausea and vomiting are intolerable, your doctor may recommend alternative food sources such as TPN (total parenteral nutrition) bags which supply your body’s essential nutrients intravenously instead of orally.

Q: What about Radiation?
A:

• Like chemotherapy, radiation aims to destroy cancerous cells.
• With TC, chemo is only used if cancer has spread outside of the testicles.  Radiation is used if the cancer is localized, if it has spread, or following surgery to make sure all cancer cells are killed.
• Radiation therapy can be used alone or can accompany chemotherapy.
• Radiation involves the use of external beams—x rays or electrons are carried by waves and directed into the cells.  They interfere with the DNA of cells. When a cancerous cell’s DNA is damaged, it cannot recover.  The cell is no longer able to replicate and will eventually die.  This stops the cancerous cells from multiplying and spreading.  It also kills the cancerous cells, shrinking tumors.
• Radiation for testicular cancer usually uses lower doses than for other types of cancers.
• When radiation is delivered, it also affects normal cells.  Fortunately, healthy cells are able to recover and repair damage better than cancerous cells, but the damage to normal cells creates unwanted side effects.  Rest periods between treatment sessions allow the body to recover.  Healthy cells affected by the radiation can work to repair damage while cancer cells cannot recover from the radiation.
• Radiation causes immediate damage to the cells, but does not kill them instantly.  For this reason, many treatment sessions may be required before the cancerous cells begin to die off, though the cells can continue dying months after treatment ends.  This could also result in the delaying of side effects—some people experience symptoms months after finishing radiation.

Q: What are the side effects of radiaton?
A:

• fatigue: many patients experience extreme fatigue after radiation treatment.  Some men find it helpful to schedule their treatment sessions in the afternoon so they can rest afterwards.
• Nausea/vomiting: this is a common side effect following radiation.  It varies in severity and length among men but usually lasts 2 to 4 hours following a session.  Talk with your doctor if you experience this side effect—he may prescribe something to help alleviate the symptoms.  Some men find it helpful to go radiation sessions with an empty stomach and to avoid eating until the nausea has passed.  Small, cold meals without fat, grease, or lots of sugars may help.  Eat and drink slowly and avoid overeating.
• diarrhea: most patients experience diarrhea a few weeks into treatment.  Your doctor may prescribe medications to help alleviate this side effect, but changes to your diet can also help.  Eat small meals and avoid foods with a high fiber content (vegetables, raw fruits, beans, grains, etc.).  Avoid dairy products.  When symptoms begin to improve, slowly incorporate fiber back into your diet.  Avoid binging.
• Sperm production may be temporarily impacted by radiation but should return to normal with time.  Sexual functioning is not affected by radiation, though sex drive may decrease as a result of fatigue.  It is recommended to wait 6-12 months after treatment ends to try to conceive just in case sperm were damaged by the radiation.  Many man have fathered healthy children following radiation treatment for TC.
• skin irritation: some men report skin irritation in the areas being treated.  Take precaution when touching skin in this area and avoid lotions/creams which would cause further irritation.

Supportive Care:

• In addition to the physical strains cancer places on a patient, emotional, financial, mental, and spiritual issues are also a concern.  Supportive care addresses these issues and helps the patient find peace.
• Supportive care is appropriate at all stages of cancer and even after remission.  It can help patients and their families adjust to life after cancer and deal with the concerns that arise.

Palliative Care/Hospice:

• Palliative care does not aim to treat or cure the disease.  The goal of palliative care is to manage symptoms/side effects and increase the quality of life.
• Hospice is generally used when treatment methods are no longer working and the patient is not expected to live longer than 6 months.
• When treatment shifts from “cure to care” during the last stage of life, hospice care aims to incorporate the patient, physicians, and family in on decision making.
• Hospice provides physical, mental, and even spiritual help for many people with advanced stage cancer and their families.
• The whole goal is more enjoyable living—it does not aim to treat or cure the disease.
• Palliative care may begin before treatment has ended or before hospice begins.
• Deciding on hospice does not mean you’re “giving up.”  During the last few months of life, it is important to be comfortable and spend time with those who matter most.  Some people enter remission while using hospice and go back to cancer treatment. For others, hospice provides the comfort and support they need.

References Cited

• American Cancer Society. How does radiation work to treat cancer? (n.d.). Retrieved from http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/radiation/radiationtherapyprinciples/radiation-therapy-principles-how-does-radiation-work
• American Cancer Society.  Surgery for testicular cancer. (2013, January 01). Retrieved from http://www.cancer.org/cancer/testicularcancer/detailedguide/testicular-cancer-treating-surgery
• American Cancer Society.  What is hospice care? (n.d.). Retrieved from http://www.cancer.org/treatment/findingandpayingfortreatment/choosingyourtreatmentteam/hospicecare/hospice-care-hospice-care
• American Society of Clinical Oncology. Treatment options. (n.d.). Retrieved from http://www.cancer.net/cancer-types/testicular-cancer/treatment-options
• Canadian Cancer Society. Supportive care for testicular cancer. (n.d.). Retrieved from http://www.cancer.ca/en/cancer-information/cancer-type/testicular/supportive-care/?region=on
• Cancer Care. Understanding and managing chemotherapy side effects. (n.d.). Retrieved from http://www.cancercare.org/publications/24-understanding_and_managing_chemotherapy_side_effects#possible-side-effects
• Cancer Treatment Centers of America. Radiation therapy for testicular cancer. (n.d.). Retrieved from http://www.cancercenter.com/testicular-cancer/radiation-therapy/
• National Hospice and Palliative Care Organization.  Palliative Care. (n.d.). Retrieved from http://www.nhpco.org/about/palliative-care
• Peckham, M. (1988). Testicular cancer. Acta Oncologica, 27(4), 439-453. doi: 10.3109/02841868809093570
• TC-Cancer.com.  Retroperitoneal lymph node dissection. (n.d.). Retrieved from http://www.tc-cancer.com/treatment/rplnd.html
• The Testicular Cancer Resource Center.  The inguinal orchiectomy. (2012, December 09). Retrieved from http://tcrc.acor.org/orch.html
• The Testicular Cancer Resource Center. Radiation therapy. (2012, December 05). Retrieved from http://tcrc.acor.org/radiation.html

Dr. Lawrence H. Einhorn, MD
1030 W. Michigan St. FL 2
Indianapolis, IN 46202
http://lawrenceeinhorn.md.com/
1 (317) 944-0920

University of Texas MD Anderson Cancer Center
www.mdanderson.org
1 (877) 632-6789

Memorial Sloan-Kettering Cancer Center – New York, NY 10065
www.mskcc.org
1 (212) 639-2000

Stanford Clinical Cancer Center – Palo Alto, CA 94304
www.Cancer.Stanford.edu
1 (650) 498-6000

Virginia Mason Medical Center – Seattle, WA 98101
www.virginamason.org
1 (844) 800-2873