Male Cancer Awareness, diagnosis and treatment
Revised 4th Edition 2 Every year in the UK over 50,000 men will be diagnosed with a male-specific cancer: prostate, testicular or penile.
This leaflet offers information on the three cancers – from signs and symptoms, risk factors and causes through to tests to determine a diagnosis and treatment options. A quick, simple visit to the GP to discuss worrying signs and symptoms can make a huge difference. The earlier the diagnosis and the sooner treatment can begin, the better the chance of survival.
www.orchid-cancer.org.uk
Introduction 3 Testicular Cancer
Although rare, testicular cancer most commonly affects men between the ages of 15-45 with over 2,200 men being diagnosed each year in the UK. Fortunately testicular cancer is highly treatable and the majority of men with early stage cancer will be cured. Research also shows that at least 98% of men diagnosed with testicular cancer in any situation will be alive 10 years after treatment. For more information on testicular cancer please see our website yourprivates.org.uk
i Spine Bladder
Pubic bone Seminal Prostate Vesicle Rectum Urethra Vas deferens Epididymis Penis Testicle Scrotum
The testicles are located inside the What is testicular cancer? scrotum, the loose bag of skin that hangs below the penis. From the start of Testicular cancer occurs when normal, puberty, each testicle produces sperm. healthy cells, which are carefully The testicles also produce 90% of the regulated in the body, begin to male sex hormone testosterone. reproduce uncontrollably in the testicles. It usually occurs in one testicle but can occur in both.
4 What are the different types of testicular cancer? lumps attached directly to the testicle(s) (usually painless) There are different types of testicular cancer. About 95% of testicular swelling or enlargement of a testicle tumours arise from the cells which line an increase in firmness the testicles and are called germ cell tumours. The most common of these is pain or discomfort in the testicle called a seminoma and is made up of a or scrotum single type of cell which is slow growing an unusual difference between and is more likely to stay within the the testicles testicle. It is more common in men over the age of 30. The remaining types, made a sudden collection of fluid in up of more than one type of cell, are the scrotum often grouped together and known as a feeling of heaviness in the non-seminoma. scrotum
a dull ache in the lower part of the Self-examination and possible abdomen, the scrotum or groin signs of testicular cancer rarely, pain in the back, not relieved It is important for men to be familiar by painkillers due to enlarged lymph with the general structure of the testicle glands (see next page) (see diagram) and what is normal for them. One testicle may be bigger than rarely, breast and nipple tenderness the other and one may hang lower but (gynaecomastia) associated with they should both be roughly the same hormonal changes caused by some types of testicular cancer. size and shape and the surface free of swelling or without any lumps. A simple, quick testicular cancer self-examination If a man finds something that doesn’t can be performed on a regular basis, feel normal it is vital that he sees his GP ideally after a warm bath or shower to rule out testicular cancer. Around 96% when the scrotum and the testicles are of abnormalities found in the scrotum relaxed. Men should be aware of any will not be testicular cancer and non changes and in particular the following: cancerous conditions can usually be easily identified. A pain in the testicle doesn’t necessarily mean cancer; there can be many causes.
For more information on non cancerous conditions please see yourprivates.org.uk.
Testicular Cancer 5 Testicular Self Examination (TSE) This is the easiest way to identify any potential testicular problems. It only takes a few minutes to perform and gives men a good excuse for feeling their balls (like they need one!). It’s best performed monthly after a bath or shower when the scrotum will be warm, relaxed and pleasant to touch. Figure 1. Men should; 1. Check each testicle separately using one or both hands (Figure 1). 2. Roll each testicle between the thumb and fingers to check that the surface is free of lumps or bumps. 3. Get to know their balls; their size, texture and anatomy. Identify the epididymis or sperm collecting tube, often mistaken for an abnormal lump that runs behind each testicle (Figure 2). Figure 2.
What are the likely causes of Intratubular germ cell neoplasia testicular cancer? (IGCN) are abnormal cells in the There is no single known cause of testicle. If left untreated, they may testicular cancer. However, research develop into cancer in about 50% studies have shown the following are of men within 5 years. risk factors: Some research suggests that taller than average men may be at an An undescended testicle increased risk. (cryptorchidism). Around 10% Men whose testicles are not of men diagnosed with testicular functioning normally are at slightly cancer will have had a history of this increased risk of developing testicular cancer. A brother or father who has had testicular cancer Men with HIV are more likely to develop testicular cancer. A previous history of testicular cancer
6 Having a vasectomy, experiencing a Treatment options: single injury to the testicles or being what are they? sexually active does not cause testicular cancer. Removing the affected testicle by surgery (orchidectomy) is the standard How is testicular cancer treatment for testicular cancer. It will diagnosed? not adversely affect someone’s sexual performance providing that the other An ultrasound scan of the testicles testicle is healthy and a prosthetic - or is extremely accurate at identifying false testicle - can be inserted in place of possible testicular cancer and if this is the removed one. suspected men will be referred to a After surgery no further treatment hospital specialist called a urologist for may be needed, providing the cancer assessment. Further investigations such has not spread beyond the testicle. as a CT scan and special blood tests will However to reduce any possibility of be performed to check for any spread of the cancer returning in the future it may cancer to other parts of the body. be recommended that a single dose of The extent to which testicular cancer has chemotherapy be given. affected the testicle or other parts of the If there is obvious evidence that the body is known as staging and treatment cancer has spread beyond the testicle will often depend on whether testicular then a longer course of chemotherapy cancer is localised to the testicle or has will be recommended. spread to lymph nodes (see below) in the abdomen or chest. Once treatment has stopped men will be monitored on a regular basis for at What are lymph nodes? least five years. The human body has a natural drainage Sex and treatment system; the lymphatic system which is responsible for getting rid of unwanted Whether someone decides to remain substances such as bacteria or waste sexually active during cancer treatment blood cells. or not is entirely a personal choice and the type of treatment will affect men in Lymph nodes are filters situated along different ways. Men will be able to talk the lymphatic drainage system. Their job to their healthcare team if they have any is to filter out and trap these unwanted concerns. substances, and to make sure they are safely eliminated from the body. Sometimes cancer cells can travel via the lymphatic drainage system to these lymph nodes and start to grow in other areas of the body.
Testicular Cancer 7 Prostate Cancer
Every year over 47,000 men in the UK will be diagnosed with prostate cancer. It is the most common cancer in men and an estimated 1 in 8 men will develop the condition. Many men in their 80s will have evidence of prostate cancer but at this age it does not usually affect their life expectancy. i Spine Bladder Pubic bone Seminal Vesicle Prostate Rectum Urethra Vas deferens Epididymis Penis Testicle Scrotum
The prostate gland is located just below What is prostate cancer? the bladder. It is only found in men and is responsible for helping to produce the Prostate cancer occurs when normal, fluid found in semen. The gland is tiny healthy cells, which are carefully at birth but grows in size after puberty regulated in the body, begin to due to rising levels of the male hormone, reproduce uncontrollably in the prostate testosterone. gland. In most cases, the growth is slow and the cancer can go undetected for many years because it causes very few symptoms. In rarer cases, however, prostate cancer grows quickly and may spread to other parts of the body, such as the lymph nodes or bones.
8 What are the symptoms? Less common symptoms There is no single symptom to indicate include the following: the presence of prostate cancer. In fact many men with early prostate cancer Blood in the urine or semen have no symptoms at all. Problems with the prostate are common. Because the prostate gland What are the likely causes of surrounds the tube known as the prostate cancer? urethra, which passes urine from the There are a number of risk factors: bladder to the outside of the body, any prostate disease or growth (benign or Age. Prostate cancer mainly affects malignant) may cause problems with men over the age of 50. It is rare in urination. men under this age. Ethnicity. Men of African Caribbean Symptoms of prostate cancer descent are more likely to develop may include the following: prostate cancer. Slow or weak flow of urine Family history of prostate cancer. Having a brother or father with Urinating more frequently or urgently than usual prostate cancer increases the risk compared to men with no family Difficulty starting to urinate history of the disease. If a first Pain or burning sensation when degree was diagnosed with prostate urinating cancer under the age of 60 the risk Unexplained urinary infection. is higher. These symptoms can also be caused Family history of breast cancer. by the prostate gland obstructing The risk increases slightly in men the bladder due to non-cancerous who have a strong family history prostate enlargement which can in of female breast cancer and vice turn affect the nerves and muscles versa (National Cancer Institute). which control urination. This is thought to be because two genes carried by both men and Difficulty getting or maintaining an erection or pain during ejaculation women (called BRCA1 and BRCA2) increase the risk of breast cancer in Impotence. women and prostate cancer in men These symptoms can also be caused (Cancer Research UK). by age, diabetes, heart or Diet. A diet high in saturated cardiovascular disease. fats and red meat may lead to an Constipation, altered bowel habit. increased risk of developing several types of cancer including prostate This symptom can also be caused by cancer. age, low intake of fibre and lack of exercise.
Prostate Cancer 9 Diet A good all round diet such as the Mediterranean diet (illustrated below) combined with exercise appears to be generally beneficial to health.
RED A few times a month MEAT Salt in moderation DESSERTS EGGS In addition - the following POULTRY substances appear FISH to offer some Snacks: Nuts in protection against A few times a week DAIRY, CHEESE ETC moderation prostate cancer; OLIVES AND OLIVE OIL pomegranate juice, Daily 6 glasses of water green tea (6 cups Red wine in a day), processed FRUIT BEANS, VEGETABLES Regular LEGUMES moderation tomatoes (found exercise in pasta and other sauces) and oily fish. BREAD - PASTA - RICE - BULGAR WHEAT AND OTHER CEREALS AS WELL AS POTATOES
How is prostate cancer Having a PSA test can be very reassuring diagnosed? if it is normal and, importantly, can help find some cancers at an early stage. Two tests are commonly used for the Unfortunately, the PSA test does miss initial investigation of prostate symptoms: some prostate cancers and it can lead to A digital rectal examination (DRE), unnecessary worry and further tests in is quick and simple to perform, and people who do not have cancer. involves a GP inserting a gloved, For more information on the PSA blood lubricated finger into the rectum (back test please see our fact sheet The PSA passage) to feel the prostate gland. blood test. A PSA (Prostate Specific Antigen) blood test measures the level of a substance produced by the prostate which can be elevated in prostate cancer. The PSA test is not a specific diagnostic test for prostate cancer as levels can be high in people who do not have the condition.
10 Prostate cancer is diagnosed definitively from samples of tissue removed from ? the prostate gland during a biopsy. It has Q. What is meant by the “grade” and also become more common to perform “stage” of prostate cancer? a special type of Magnetic Resonance A. If a man is diagnosed with prostate Imaging scan (MRI) before taking biopsy cancer, a specialist healthcare team samples from the prostate gland to will need to identify the “grade” identify and target potentially cancerous or aggressiveness of the cancer areas. in order to determine the best If a man is diagnosed with prostate course of treatment. The “grade” cancer the specialist healthcare team of cancer is determined through may carry out additional tests and scans a biopsy of the prostate gland such as an MRI and bone scan to identify and the system used to measure cancer that has spread beyond the the grade is called the Gleason prostate gland. grading system. If the cancer is slow The results of these investigations and growing, and not aggressive, it will the biopsy will be used to give the have a low “Gleason score”. prostate cancer a stage (how far it has spread; see picture below). This can be summarised as T stage where T stands for tumour. Other terms such as lymph node involvement (see page 7), and spread of cancer to bones may be discussed and are referred to in letter form as N and M respectively.
Bladder Spine Prostate T 1 Bladder T2 Rectum
T3 Prostate
T4 Tumour invading other structures
Prostate Cancer 11 Treatment options: Choice of treatment will depend on what are they? a large number of factors, and every individual will be assessed carefully before There are a number of treatment options any treatment decisions are made. A team for prostate cancer: of urologists, oncologists and other health professionals called a Multi Disciplinary Team (MDT) will discuss all of the available Active surveillance and “watchful results and make a recommendation waiting” for a particular treatment(s) based on Surgery (open, keyhole or robotic their knowledge and experience. This surgery) recommendation will then be discussed with the patient. The following tables Radiotherapy contain a list of treatment options, when Hormone therapy they are used and the drawbacks that may occur when having specific treatments. Chemotherapy.
Treatment option When it’s used Drawbacks
Active Often used for men with low-risk or slow- Can lead to surveillance growing cancers. It involves close monitoring anxiety while with regular check-ups; PSA tests, DREs and waiting to see usually further biopsies after a year or eighteen if cancer will months. Curative treatment can be commenced progress. if there is any sign of the cancer progressing or a patient were to change their mind and opt for treatment. Active surveillance prevents men rushing into treatment for their cancer which may cause unwanted side effects when the cancer may not progress or cause any problems for some time.
“watchful waiting” This is used for older men or men who may not be fit enough for a particular treatment and have no obvious symptoms. Surgery Can be used when cancer remains localised. Can cause It will involve the removal of the whole prostate erection and seminal vesicles and occasionally lymph problems nodes (see page 7). There are several types of or urinary surgery including “open”, keyhole (laparoscopic) incontinence. and robotic. No type of surgery has been proved to be better than the others with regard to possible side effects although recovery time will be quicker with laparoscopic or robotic surgery.
12 Treatment option When it’s used Drawbacks
Radiotherapy Is used as an alternative to surgery. Can be Can cause either external (where an external beam is erection and directed at the cancer) or internal (where urinary problems radioactive seeds are placed into or near the and sometimes cancer – this is known as “brachytherapy”). minor bowel Brachytherapy is usually used if the cancer damage. is confined to the prostate gland whereas external beam and a newer type of radiotherapy treatment Intensity Modulated Radiotherapy (IMRT) can be used to treat early spread of cancer beyond the prostate.
Hormone therapy Used to slow cancer growth and reduce Can cause hot tumour size. Usually used when cancer flushes, loss of has spread beyond the prostate to other sex drive and organs or the bones. It works by removing weakened bones. or blocking the male hormone, testosterone, Eventually, cells which encourages growth of prostate cancer. become immune It is usually very effective at, regressing and and other controlling prostate cancer but does not cure treatments may be the disease. needed.
Also used before external beam radiotherapy for localised disease and sometimes for several years after radiotherapy if cancer has spread onto the surface of the prostate or into the seminal vesicles.
Chemotherapy Combinations of steroids, chemotherapy or Treatment will new treatments new types of hormone therapy can be used have side effects and combination when initial hormone therapy has failed. that may affect a treatment. mans quality of life.
Prostate Cancer 13 New treatments Treatment options: longer term There are many new treatments for The treatment offered to each person prostate cancer under development will be regularly reviewed and may and these include: change over time. For example a specific treatment may no longer work, there may High-intensity focused be unwelcome side effects or a more ultrasound (HIFU). effective option becomes available. The HIFU is a treatment that uses ultrasound (high-energy sound waves) to destroy specialist healthcare team will support cancer cells. It is currently used as a people through this process. treatment for prostate cancer that has returned following radiotherapy but is Sex and treatment also being evaluated for treatment as an Whether someone decides to remain alternative to surgery or radiotherapy as sexually active during cancer treatment initial treatment as a clinical trial in some or not is entirely a personal choice and but not all treatment centres. the type of treatment will affect men in Gene and immunotherapy. different ways. Men may wish to talk to This treatment uses the individual’s own their specialist healthcare team if they immune system to fight cancer. Substances have any concerns. made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against cancer. ?
Q. What are clinical trials? A. Some people with cancer may be considered for a clinical trial during their course of treatment. These trials are an important part of the cancer research process. Individuals who take part in a clinical trial may receive the standard treatment for their cancer or be among the first to receive a new treatment. Many newer treatments are being developed to treat prostate cancer and men with more advanced disease may be asked to take part in trials to evaluate the effectiveness of newer treatments if they are diagnosed with prostate cancer.
Penile cancer is a rare cancer and affects over 600 men each year. It is more common in men over the age of 50 years although younger men can be affected and up to 25% of men affected will be under this age. i Spine Bladder Pubic bone Seminal Vesicle Prostate Rectum Urethra Vas deferens Epididymis Testicle Penis Scrotum
The penis is the external male sexual What is penile cancer? organ. The main part of the penis is known as the shaft and the head of Penile cancer occurs when normal, the penis is called the glans. At birth healthy cells, which are carefully the glans is covered by a loose piece of regulated in the body, begin to skin, known as the foreskin which may reproduce uncontrollably. In most cases, be removed in infancy - this is known this growth is slow. as circumcision. Inside the penis is the urethra, the tube through which urine and semen exit the body.
Penile Cancer 15 Possible signs of penile cancer If an initial examination or course of treatment does not “clear up” or resolve Common signs include: the symptoms within a few weeks it is important to seek a referral to a White or red scaly patches urologist who may request further Red moist patches of skin investigation. This may include a sample of tissue (a biopsy) being taken from the Change in the colour of the skin penis or a circumcision. If penile cancer is found, a referral to a specialist centre or Skin thickening Supra-Network will be made. Growth, bump or sore. ? What are the likely causes of Q. What is a Supra-Network? penile cancer? A. Supra-Network centres are There is no single known cause of penile designed to treat specialist or rarer cancer. However, research studies have cancers. At these centres there will shown the following may play a role in be a multi-disciplinary specialist penile cancer: team which will include surgeons, oncologists, radiologists, clinical nurse specialists and counsellors. The human papilloma virus (HPV). Two strains of this virus HPV 16 and 18 are linked with penile cancer. The specialist healthcare team will carry Penile cancer is less common in out a series of blood tests, examinations men who have had their foreskin and scans to identify the stage and removed (been circumcised) soon grade of the cancer and whether it has after birth. spread beyond the penis. This will help to determine the best course of treatment. How is penile cancer diagnosed? It can be very difficult to recognise the signs and symptoms of penile cancer. Many GPs will never see someone with the disease during their lifetime. Many of the symptoms mentioned are also associated with other diseases, some of which may be sexually transmitted.
16 Treatment options: a photosensitising agent) to destroy what are they? abnormal cells. PDT is only available at specialist centres. There are three possible types of treatment available to men: surgery, radiotherapy and chemotherapy. ? Surgery is the most common treatment Q. Why might you be recommended option for penile cancer. Removing small, or refused a specific treatment? surface cancers that have not spread A. No two cases of cancer are the can be performed using minor surgery. same. The grade and stage of the Removal of part or all of the penis is cancer will vary, as will the medical recommended if the cancer has spread history and general health of the to a wider area. Total removal of the person being treated. The specialist penis also known as a penectomy is healthcare team (MDT) will now much less common, as surgeons consider all these factors before can usually preserve much of the tissue. recommending a specific course Reconstructive surgery is sometimes of treatment. They will also want possible to restore the appearance of to consider the side effects of the the penis. Lymphadenectomy involves treatment and how this might affect the surgical removal of lymph nodes (see a man’s quality of life. page 7) in the groin area. This is an option Q. What is palliative care? if it is suspected that the cancer has spread beyond the penis. A. If the cancer is very advanced or if it has spread to other parts of Radiotherapy and chemotherapy are the body there may be limited usually used to treat more advanced treatment options. In this case the penile cancer, however chemotherapy specialist healthcare team will offer cream may sometimes be used to palliative care to help relieve pain or treat very small, early cancers that are other symptoms. confined to the foreskin or end of the penis. Radiotherapy may be used instead of Sex and treatment surgery when someone is not well The type of treatment will affect men in enough to have an operation or doesn’t different ways. Most treatments for penile want to have surgery. cancer will not affect the ability to have Photodynamic therapy (PDT) is a new sex but for men who have had some or type of treatment which is being tested all of their penis removed this ability will for treating penile cancer. It uses laser, or be affected. Access to specialist support other light sources combined with a light from counsellors or sex therapists sensitive drug (sometimes called is important both during and after treatment.
Penile Cancer 17 Resources For further information and support PSA Factsheet on male cancer, please visit the Orchid Penile Cancer Booklet and www.orchid-cancer.org.uk website at Information Leaflets or call 0203 745 7310 or contact the nurse helpline below. Low-down, Orchid’s newsletter features the latest news and developments Orchid has produced a series of leaflets in male cancer including research, and Factsheets on specific issues treatments, new services and events. relating to male cancer. You may find the following helpful: Other helpful websites include: Testicular Cancer - all you need to www.cancerhelp.org – which offers a broad know booklet range of information and support from Cancer Research UK for everyone affected Testicular Cancer and Your Fertility by cancer. www.macmillan.org.uk Ball Basics - a quick guide to – offers information testicular health and testicular and support for everyone affected by cancer. cancer www.prostatecanceruk.org – Prostate Cancer UK provides support and Prostate Cancer and You - a quick information to people affected by prostate guide to prostate cancer cancer. i Orchid has a Male Cancer Helpline manned by specialist nurses on 0808 802 0010 or email [email protected]
18 Conclusion We hope the information provided in this leaflet has been helpful. You should always consider speaking to your specialist healthcare team or GP about any healthcare concerns and you may wish to take this leaflet with you when you meet them.
Conclusion 19 References to sources of information used in this booklet are available from Orchid.
Orchid is the UK’s leading charity If you have any queries regarding the dedicated to supporting men and information contained in this booklet their families who are affected by please contact the Orchid Team on: male-specific cancers:- testicular, Tel: 0203 745 7310 prostate and penile. Fax: 0207 388 1175 Established in 1996 by a young References are available on request. testicular cancer patient and the oncologist who saved his life, Orchid Written and edited by: works to improve the lives of people Orchid Cancer Appeal and affected by male cancers through Orchid Editorial Board a world class research programme, December 2015. educational campaigns and raising To be reviewed 2017. awareness and an extensive support service.
Orchid has a Male Cancer Helpline manned by specialist nurses on 0808 802 0010 or email [email protected]
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Models featured in this brochure are used for illustrative purposes only.