Testicular Cancer: Serve the Survivors
Testicular cancer, by nature, is one of the most aggressive solid organ tumours. It can spread to virtually every part of the body but commonly to lymph nodes, lungs, and brain. If left untreated, it will cause death in the majority of patients within the first year of diagnosis. Treatment involves a multi-modality approach utilising chemotherapy, radiotherapy, and surgery. Since the birth of cisplatin-based chemotherapies in the 1970s, a cure can be achieved in more than 90% of cases.
This high cure rate for around 50 years has resulted in a significant number of survivors. As testicular cancer is commonly diagnosed in the early years of life, these survivors live long enough to experience the late side effects of treatment, which are not observed in other patient groups.
As early as the early 90s, oncologists started observing the late side effects in this population, but in the last decade, we have seen an exponential amount of research in this area. Of note, a registry-based research performed on Scandinavian, American, and Canadian subjects revealed a worrisome picture of this particular cohort. The study showed a downward trend in life expectancy of testicular cancer survivors while it was improving in the general population for the last five decades. Further investigations showed second cancers as the most common cause of death, followed by early cardiovascular disease. With these revelations, more research was carried out on the survivors in the last five years. It has been established now that the late side effects are associated with the treatment modalities used for the cure of cancer, in particular, chemotherapy and radiotherapy, being the major culprits. In addition to early deaths, these sequelae cause excessive disease burden in the survivors, ultimately affecting their economic, social, and sexual health. Other side effects commonly reported in this cohort include hypertension, dyslipidaemia, hypogonadism, obesity, lung disease, kidney disease, deafness, tinnitus, peripheral neuropathy, and infertility. Fear of cancer recurrence and anxiety are the most common psychological consequences in the survivors.
Radiotherapy to abdominal lymph nodes results in a higher incidence of abdominal malignancies, including stomach, pancreas, bowels, and prostate cancer. Therefore, it is now only being used in exceptional circumstances. It is still routinely used to treat the brain mets, which can cause cognitive decline in survivors.
Cisplatin-based chemotherapy regimens are still widely used for the treatment of testicular cancer. Plenty of efforts have been made to reduce its exposure in the last decade. Firstly, its use in the stage I disease after orchiectomy is almost abandoned, with preference being given to surveillance only. For stage II disease, with cancer present in abdominal lymph nodes, surgical resection without chemotherapy is widely being investigated and discussed at the moment. This approach, however, requires highly skilled and specialised surgical teams performing surgeries in high-volume cancer centres. Chemotherapy remains the only option in stage III disease except for a small number of cancers which do not respond to chemotherapy and require surgery.
Reducing the exposure to chemotherapy and radiotherapy will definitely improve the incidence of late side effects in survivors. But there is a dire need to address the challenges being faced by the patients who are exposed to these treatments in the past. Unfortunately, our progress in survivorship care has not been satisfactory so far, marked by the absence of any specialised pathways and services.
As an oncology team in Tallaght University Hospital, Dublin, we acknowledged this dire need for specialised services and established a nurse-led clinic for testicular cancer survivors. A similar clinic is recently developed in St James’s Hospital, Dublin, while work is in progress to include more cancer centres. More than 100 patients were screened by our team to assess the prevalence of mortality and morbidity in Irish testicular cancer survivors. Furthermore, we laid down the basis of a national prospective registry for survivors to study the trends in this population. This study, SLECT, is being conducted in collaboration with Cancer Trials Ireland and has been actively recruiting for the last 2 years.
In an effort to improve the health of survivors, referral pathways and services are being set up, specifically designed for this cohort. While we have been successful in many aspects, a big hiatus in service delivery remains, and the work continues.
Written by Dr M Raheel Khan, Consultant Medical Oncologist, St James’s Hospital, Dublin
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