The three basic types of treatment are
surgery,
radiation therapy, and
chemotherapy. Surgery is performed by
urologists; radiation therapy is administered by
radiation oncologists; and chemotherapy is the work of medical
oncologists. In most patients with testicular cancer, the disease is cured readily with minimal long-term
morbidity. While treatment success depends on the stage, the average survival rate after five years is around 95%, and stage 1 cancer cases, if monitored properly, have essentially a 100% survival rate.
Testicle removal The initial treatment for testicular cancer is surgery to remove the affected testicle (
orchiectomy). While it may be possible, in some cases, to remove testicular cancer tumors from a testis while leaving the testis functional, this is seldom done, as the affected testicle usually contains pre-cancerous cells spread throughout the entire testicle. Thus, removing the tumor alone without additional treatment greatly increases the risk that another cancer will form in that testicle. Since only one testis is typically required to maintain fertility, hormone production, and other male functions, the affected testis is almost always removed completely in a procedure called
inguinal orchiectomy. (The testicle is rarely removed through the scrotum; an incision is made beneath the belt line in the inguinal area.) In the UK, the procedure is known as a radical orchidectomy.
Retroperitoneal lymph node dissection In the case of
non-seminomas that appear to be stage I, surgery may be done on the
retroperitoneal/
paraaortic lymph nodes (in a separate operation) to accurately determine whether the cancer is in stage I or stage II and to reduce the risk that
malignant testicular cancer cells that may have
metastasized to lymph nodes in the lower abdomen. This surgery is called
retroperitoneal lymph node dissection (RPLND). However, this approach, while standard in many places, especially in the United States, is out of favor due to costs and the high level of expertise required to perform successful surgery. Sperm banking is frequently carried out before the procedure (as with chemotherapy), as there is a risk that RPLND may damage the nerves involved in ejaculation, causing ejaculation to occur internally into the bladder rather than externally. Many patients are instead choosing surveillance, where no further surgery is performed unless tests indicate that the cancer has returned. This approach maintains a high cure rate because of the growing accuracy of surveillance techniques.
Adjuvant treatment Since testicular cancers can spread, patients are usually offered
adjuvant treatment— in the form of
chemotherapy or
radiotherapy— to kill any cancerous cells that may exist outside of the affected testicle. The type of adjuvant therapy depends largely on the
histology of the tumor (i.e., the size and shape of its cells under the microscope) and the stage of progression at the time of surgery (i.e., how far cells have 'escaped' from the testicle, invaded the surrounding tissue, or spread to the rest of the body). If the cancer is not particularly advanced, patients may be offered careful surveillance by periodic
CT scans and blood tests, in place of adjuvant treatment. Before 1970, survival rates from testicular cancer were low. Since the introduction of
adjuvant chemotherapy, chiefly platinum-based drugs like
cisplatin and
carboplatin, the outlook has improved substantially. Although 7000 to 8000 new cases of testicular cancer occur in the United States yearly, only 400 men are expected to die of the disease. In the UK, a similar trend has emerged: since improvements in treatment, survival rates have risen rapidly to cure rates of over 95%.
Radiation therapy Radiation may be used to treat stage II seminoma cancers, or as
adjuvant (preventative) therapy in the case of stage I seminomas, to minimize the likelihood that tiny, non-detectable tumors exist and will spread (in the inguinal and para-aortic
lymph nodes). Radiation is ineffective against and is therefore never used as a primary therapy for
non-seminoma.
Chemotherapy Non-seminoma Chemotherapy is the standard treatment for non-seminoma when the cancer has spread to other parts of the body (that is, stage 2B or 3). The standard
chemotherapy protocol is three, or sometimes four, rounds of
Bleomycin-
Etoposide-
Cisplatin (BEP). BEP as a first-line treatment was first reported by Professor
Michael Peckham in 1983. The landmark trial published in 1987 which established BEP as the optimum treatment was conducted by Dr.
Lawrence Einhorn at
Indiana University. An alternative, equally effective treatment involves the use of four cycles of
Etoposide-
Cisplatin (EP). Lymph node surgery may also be performed after chemotherapy to remove masses left behind (stage 2B or more advanced), particularly in the cases of large
non-seminomas.
Seminoma As an
adjuvant treatment, the use of
chemotherapy as an alternative to radiation therapy in the treatment of seminoma is increasing, because radiation therapy appears to have more significant long-term side effects (for example,
pelvic radiation disease, increased risks of secondary malignancies, etc. See also: Radiation therapy#Late side effects). Two doses, or occasionally a single dose of
carboplatin, typically delivered three weeks apart, is proving to be a successful
adjuvant treatment, with recurrence rates in the same ranges as those of
radiotherapy. The concept of
carboplatin as a single-dose therapy was developed by Tim Oliver, Professor of Medical Oncology at
Barts and The London School of Medicine and Dentistry. However, very long-term data on the efficacy of adjuvant carboplatin in this setting do not exist. Since seminoma can recur decades after the primary tumor is removed, patients receiving adjuvant chemotherapy should remain vigilant and not assume they are cured 5 years after treatment. ==Prognosis==