Understanding Testicular Cancer

Take-home points

• Testicular cancer primarily affects young men, and early detection is crucial through recognising symptoms like lumps, pain, size changes, and lower abdominal discomfort.
• Having a family history of testicular cancer significantly increases the risk of developing the disease, with a father's history increasing the risk fourfold, and both a father and sibling's history increasing it eightfold.
• Prompt diagnosis is vital, with physical examinations, ultrasounds, blood tests, and biopsies helping confirm testicular cancer, while regular testicular self-examinations aid in early detection.
• Treatment options include surgery, radiation therapy, chemotherapy, and surveillance, with a positive prognosis when detected and treated early. ‍

Understanding Testicular Cancer

Testicular cancer is an uncommon cancer that commonly affects men aged between 15 and 49 and represents around 1% of all cancers in men.^1,2 It develops in the testicles, which are part of the male reproductive system responsible for producing sperm and testosterone.³ However, despite the greater emphasis on testicular cancer awareness over the years, the incidence of testicular cancer has continued to grow, doubling over the past 4 decades.⁴

Testicular cancer risk factors stem from both genetic and environmental causes, though with advancements in both medicine and technology, we’re able to better evaluate signs of testicular cancer and manage the disease accordingly, making it one of the most curable cancers.² As it currently stands, testicular cancer prognosis is around 90%, with a greater than 95% 5-year survival rate.²

What Is Testicular Cancer?

Testicular cancer occurs when cells in one or both testicles start to grow and divide in an uncontrolled and abnormal manner, eventually forming a tumour.⁵ There are different types of testicular cancer depending on the type of cell in which the cancer originates.⁵ The most common form of testicular cancer, testicular germ-cell tumour, occurs in around 90% of cases and originates from the cells that make the sperm.⁵

Testicular germ-cell tumours can be further broken down into two subcategories: seminomas, which grow more slowly and are more sensitive to radiation therapy; and non-seminomas, which are more liable to spread or metastasize.^6,7 There are, however, other, less common forms of testicular cancer, such as Leydig cell tumours, Sertoli cell tumours, and yolk sac tumours, among others.²

Symptoms Of Testicular Cancer

Knowing the symptoms of testicular cancer is crucial for early detection and successful treatment.² However, testicular cancer can be tricky to spot due to its symptoms being rather unspecific, making a testicular cancer diagnosis more difficult to obtain.  

Most patients would present with a painless lump or swelling in the testes, which is often discovered by accident.² These lumps may be the size of a pea or as large as a golf ball, and in 10% of cases may cause an individual to experience ongoing dull pain. Other more common symptoms of testicular cancer include:⁸

• A change in shape, size, or texture of one or both testicles.
• A feeling of heaviness or fullness in the scrotum.
• A notable difference in appearance between the testicles.

Some men and people with testicles may not display any symptoms of testicular cancer until the cancer has spread.² If testicular cancer spreads to different parts of the body, the symptoms an individual may experience will be more generalised. These include:²  

• Ongoing fatigue.
• Weight loss.
• Shortness of breath or cough.
• Enlarged lymph nodes.

What causes testicular cancer?

As with many cancers, the exact cause of testicular cancer is still unknown, but a number of risk factors have been identified.  

Cryptorchidism (undescended testicle)

A common birth defect to affect the male genitalia is cryptorchidism, a condition whereby at least one of the testicles is absent from the scrotum.⁹ This occurs in around 3% of boys and it often corrects itself within the first year of life.⁹ However, in certain cases, the testicle remains undescended and can lead to a number of complications such as infertility, testicular torsion (twisting of the tubes that carry the sperm), and an increased risk of testicular cancer.⁹

Family History

Boys, men, and people with testicles who have a family member with a history of testicular cancer or cryptorchidism have a higher risk of developing testicular cancer.¹⁰ In fact, almost half of the risk of developing testicular cancer is attributed to the passing down of genes from parent to child.¹¹

According to the NHS, having a father who has had testicular cancer increases your risk of developing the condition by four times, while having both a father and a sibling affected raises the risk to eight times higher than average.¹

Infertility

Studies demonstrate that subfertile people with testicles are at a greater risk of developing testicular cancer.¹² Although reasons why this occurs are yet to be set in stone, hypotheses suggest that the correlation may be due to an abnormality in hormone regulation among those who are infertile.¹²

How Is Testicular Cancer Diagnosed?

If you notice any changes in how your testicles look or feel, we recommend you see a doctor as soon as possible. Your doctor will carry out a thorough history and perform a careful physical exam which includes feeling the testes and the area around the testes to check if a firm lesion or mass is present.² To confirm a diagnosis and to check the stage of testicular cancer, your doctor may refer you for some additional testing, which includes:²

• Trans-scrotal ultrasound: an ultrasound is the primary imaging technique used to identify testicular cancer. This procedure is painless and involves manoeuvring a small device over the scrotum which then relays images of your testicles back to the doctor for examination.¹³  
• Blood tests: certain cancers may release markers into the bloodstream which can be identified by a blood test. Some testicular cancers produce high levels of these markers, such as alpha-fetoprotein and human chorionic gonadotropin.¹⁴  
• Biopsy: a biopsy involves removing and examining a part of a lump under a microscope. Though not routinely offered, a biopsy may be recommended depending on your symptoms and the stage of testicular cancer you may have.¹⁵  
• Further imaging: you may be referred for a computerised tomography (CT) scan and chest x-ray to determine whether the cancer has spread.¹⁶
  

How To Check For Testicular Cancer At Home

Discovering testicular cancer early increases your chances of survival.² The best way to check yourself for any lumps or bumps is by carrying out a testicular self-examination around once a month. A testicular self-examination is a process whereby you check your testicles for any changes in size, colour, shape, or appearance.¹⁷ It is best for you to do this when in the shower or bath, as warm water helps relax your scrotum and makes it easier to examine.  

Below is a short step-by-step testicular self-examination guide for you to follow:

1. Hold your penis out of the way and examine each testicle separately.
2. Gentle roll each testicle between your thumb and fingers, feeling for any lumps, swelling, hardness, or changes in size. Do not be alarmed if you can feel your sperm ducts, as these naturally stick out of your testes.
3. Feel for any pain in either testicle.
4. Compare the testicles to one another. It is normal for one to be slightly larger or hang lower than the other. If this difference changes upon your next examination, you should get it checked out by your doctor.  

Testicular Cancer Treatment

Testicular cancer is treated depending on the type of disease you have, the stage of the disease, and its clinical presentation.² The main treatment for testicular cancer is the surgical removal of the affected testicle, otherwise known as an orchidectomy.¹⁶ This is a minimally invasive procedure often carried out through a small cut in your groin.

Depending on the stage and type of disease you have, you may also require further treatment using chemotherapy, radiotherapy, or both.¹⁶ The best testicular cancer treatment for you will depend on several factors which your specialist will discuss with you to help you make an informed decision.¹⁶

Sperm Bank

In the UK, you will also be given the opportunity to donate to a sperm bank prior to your surgery.^16,18 After undergoing the removal of one testicle, the impact on fertility can vary, affecting some individuals while leaving others unaffected.¹⁸ Additionally, certain treatments such as chemotherapy may too affect your sperm count, so you may want to consider sperm banking before your treatment.¹⁸

Testosterone Replacement

Having one testicle removed should not alter the production of testosterone unless the remaining testicle is not functioning properly.¹⁸ In such cases, you may be provided with testosterone replacement therapy in the form of injections, skin patches, or gels.¹⁸

Conclusion

Testicular cancer is a rare but highly treatable form of cancer. However, due to its occurrence rising over the years, it's important to raise greater testicular cancer awareness so that men can learn how to identify signs of testicular cancer early and catch it before it spreads. If you have any signs or symptoms of testicular cancer, you must make an appointment with your doctor as soon as possible. Remember to check your testicles at least once per month to make sure everything stays in check.

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References:

1. NHS. Testicular Cancer [Internet]. NHS; 2022 [cited 2023 Jun 15]. Available from: https://www.nhs.uk/conditions/testicular-cancer/.  
2. Gaddam SJ, Chesnut GT. Testicle Cancer. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Jun 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563159/.  
3. Shalet SM. Normal testicular function and spermatogenesis. Pediatric Blood & Cancer. 2009;53(2):285–8. doi:10.1002/pbc.22000.    
4. Boccellino M, Vanacore D, Zappavigna S, Cavaliere C, Rossetti S, D’Aniello C, et al. Testicular cancer from diagnosis to epigenetic factors. Oncotarget. 2017;8(61):104654–63. doi:10.18632/oncotarget.20992.  
5. Rajpert-De Meyts E et al. Testicular Cancer: Pathogenesis, Diagnosis and Management with Focus on Endocrine Aspects. 2023 [cited 2023 Jun 15]. In: Feingold KR, Anawalt B, Blackman MR, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278992/.
6. Jonska-Gmyrek J, Peczkowski P, Michalski W, Poniatowska G, Zolciak-Siwinska A, Kotowicz B, et al. Radiotherapy in testicular germ cell tumours – a literature review. Współczesna Onkologia. 2017;3:203–8. doi:10.5114/wo.2017.69592.  
7. Nauman M, Leslie SW. Nonseminomatous Testicular Tumors. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Jun 15]-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568754/.
8. NHS. Testicular Cancer Symptoms [Internet]. NHS; 2022 [cited 2023 Jun 15]. Available from: https://www.nhs.uk/conditions/testicular-cancer/symptoms/.  
9. Leslie SW et al.Cryptorchidism.[Internet]StatPearls Publishing; 2023 [cited 2023 Jun 15]-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470270/.
10. Bromen K et al. Testicular, other genital, and breast cancers in first-degree relatives of testicular cancer patients and controls. Cancer Epidemiol Biomarkers Prev. 2004 Aug;13(8):1316-24. PMID: 15298952.
11. The Institute of Cancer Research. Nearly half of testicular cancer risk comes from inherited genetic faults [Internet]. 2015 [cited 2023 Jun 15]. Available from: https://www.icr.ac.uk/news-archive/nearly-half-of-testicular-cancer-risk-comes-from-inherited-genetic-faults.
12. ‍Moller H, Skakkebak NE. Risk of testicular cancer in subfertile men: Case-control study. BMJ. 1999;318(7183):559–62. doi:10.1136/bmj.318.7183.559.
13. Kühn AL, Scortegagna E, Nowitzki KM, Kim YH. Ultrasonography of the scrotum in adults. Ultrasonography. 2016;35(3):180–97. doi:10.14366/usg.15075.  
14. Montgomery J, Weizer A, Filson C, Milose J, Khaled Hafez. Role of biochemical markers in testicular cancer: Diagnosis, staging, and surveillance. Open Access Journal of Urology. 2011;1. doi:10.2147/oaju.s15063.  
15. NHS. Testicular Cancer - Diagnosis [Internet]. NHS; 2022 [cited 2023 Jun 15]. Available from: https://www.nhs.uk/conditions/testicular-cancer/diagnosis/.
16. Baird DC, Meyers GJ, Hu JS. Testicular Cancer: Diagnosis and Treatment. Am Fam Physician. 2018 Feb 15;97(4):261-268. PMID: 29671528.
17. Macmillan Cancer Support. How to check for testicular cancer [Internet]. [cited 2023 Jun 15]. Available from: https://www.macmillan.org.uk/cancer-information-and-support/testicular-cancer/how-to-check.
18. ‍NHS. Testicular Cancer - Treatment [Internet]. NHS; 2022 [cited 2023 Jun 15]. Available from: https://www.nhs.uk/conditions/testicular-cancer/treatment/.