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Home , Testicular cancer

Male Awareness, diagnosis and treatment

Revised 2nd Edition 2 Every year in the UK over 43,000 men will be diagnosed with a male-specific cancer:- prostate, testicular or . Many of us will know someone who has been diagnosed with a male-specific cancer.

This leaflet offers information on the three – from , risk factors and causes through to tests to determine a diagnosis and treatment option. 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

Testicular cancer is the most common cancer in men aged 15-45. Every year over 2,200 men in the UK will be diagnosed with the . Fortunately, testicular cancer is highly treatable. If caught early, 98% of men will make a full recovery, and even in the later stages of the disease, the cure rate is very high compared to other cancers with 96% of men diagnosed with testicular cancer being alive 10 years after treatment. For more information on testicular cancer please see yourprivates.org.uk i Spine Bladder Pubic bone Seminal Prostate Vesicle Rectum Urethra Vas deferens Penis

The are located inside the What is testicular cancer? scrotum, the loose bag of skin that hangs below the penis. From the start of A testicular tumour is a lump created by puberty, each testicle produces sperm. the abnormal and uncontrolled growth The testicles also produce the of cells. They can occur in one or both testosterone. testicles.

4 What are the different types of testicular cancer? lumps in or on either testicle There are a number of different types swelling or enlargement of the testicle of testicular cancer. About 95% of testicular tumours arise from the germ an increase in firmness cell epithelium which lines the testicular tubes and are known as germ cell pain or discomfort in the testicle tumours. The most common of these or scrotum is called a and is made up an unusual difference between of a single type of cell which is slow the testicles growing and tends to stay localised in the testicle for a long period of time. It a sudden collection of fluid in the scrotum tends to affect men over the age of 30. The remaining types, made up of more a feeling of heaviness in the than one type of cell, are often grouped scrotum together and known as non-seminoma. a dull ache in the lower part of the They usually affect younger men and , the scrotum or groin tend to be more aggressive. There are other types of cancer which can start in rarely, pain in the back, not relieved the testicles but these are rare. by painkillers due to enlarged lymph glands Self-examination and possible rarely, breast and nipple tenderness signs of testicular cancer (gynaecomastia) associated with hormonal changes caused by It is important for men to know the testicular cancer. look and feel of their testicles and to recognise any changes. A simple, quick testicular cancer self-examination can It is important that further advice be be done on a regular basis, ideally after sought as soon as possible but there is a warm bath or shower. Men should be no need to panic - most lumps are not aware of any changes and in particular cancer and a pain in the testicle doesn’t the following: 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 you a good excuse for feeling your nads (like you need one!). It’s best performed monthly after you have had a bath or shower when your scrotum will be warm, relaxed and pleasant to touch. Figure 1. 1. Check each testicle separately using one or both of your hands (Figure 1). 2. Roll each testicle between the thumb and forefinger to check that the surface is free of lumps or bumps. Do not squeeze! 3. Get to know your balls; their size, texture, anatomy, magnificence. Identify the epididymis or sperm collecting tube, often mistaken for an abnormal lump that runs behind each testicle (Figure 2). 4. Encourage your partner to have a go as he or she may be more likely to identify a problem in the future and get you to do something about it. Figure 2.

What are the likely causes of A sedentary lifestyle and repeated testicular cancer? testicular knocks or trauma may There is no single known cause of increase the risk of testicular cancer testicular cancer. However, research Intratubular germ cell neoplasia studies have shown the following may (IGCN) means that there are make testicular cancer more likely: abnormal cells in the testicle. If left untreated, it will develop into cancer in about half the men who have it An undescended testicle (50%) (). Research has shown the risk of testicular cancer Some research suggests that taller increases dramatically if this is not than average men may be at an corrected by the age of 11 increased risk. A brother or father who has had testicular cancer Having a vasectomy, experiencing a single injury to the testicles or being A previous diagnosis of testicular cancer sexually active does not cause testicular cancer.

6 How is testicular cancer removed, although this is only possible diagnosed? under specific conditions and is not considered standard treatment. If a man finds a lump in their testicle After it may not be necessary and is seen by their GP, an ultrasound to give any further treatment, providing scan of the testicles is usually arranged the cancer has not spread beyond the and a referral is made to a specialist testicle. This form of treatment is known called a urologist for assessment. If the as surveillance. However to reduce any scan shows that there is a possibility of possibility of the cancer returning in the testicular cancer then blood tests to look future it may be recommended that a for substances produced by testicular single dose of be given. cancer( tumour markers) and a CT scan If there is obvious evidence that the are usually requested. cancer has spread beyond the testicle Understanding how far testicular cancer then chemotherapy will usually be has spread is called staging. It is important recommended. to know at what stage the cancer is, in Chemotherapy in this situation is usually order for appropriate treatment to be finished within 3 months and most men given. This will depend on whether the have made a complete recovery within cancer is confined to the testicle, or has 6 months. Once treatment has stopped spread to lymph nodes in the abdomen men will be monitored on a regular basis or chest. for at least five years by their oncologist. CT scans will be performed to make Treatment options: sure the cancer has not come back. what are they? Removing the affected testicle and Sex and treatment tumour by surgery (orchidectomy) is the Whether someone decides to remain standard treatment for testicular cancer sexually active during cancer treatment where the cancer has remained within or not is entirely a personal choice and the testicle(s). This is usually done quickly the type of treatment will affect men and within a two week period. It will in different ways. It is important to use not adversely affect someone’s sexual appropriate contraception / protection performance and a prosthesis - or false during this time and there are issues testicle - can be inserted in place of the about fertility which should be discussed removed one. This can be performed a with the specialist healthcare team. few months after the initial operation. Another option is surgery involving a lumpectomy where just the tumour is

Testicular Cancer 7

Every year over 41,000 men in the UK will be diagnosed with prostate cancer. It is the most common cancer in men over the age of 55 years, and an estimated 1 in 8 men will develop the condition. Most men in their 80s will have evidence of prostate cancer but at this age it usually does not 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 Prostate cancer occurs when normal, the fluid in semen. The gland is tiny at healthy cells, which are carefully birth but grows in size after puberty due regulated in the body, begin to 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 some cases, however, prostate cancer grows quickly and may spread to other parts of the body, such as the lymph nodes or bones.

8 Possible signs of prostate What are the likely causes of cancer prostate cancer? There is no single symptom to indicate There are a number of risk factors: the presence of prostate cancer. Many men will have no symptoms at Age. Prostate cancer mainly affects all. Problems with the prostate are men over 65. It is rare in men under common; they may not necessarily be 50 years of age, but more than caused by cancer, and may result in 1,000 men under 55 years of age slowly developing symptoms that can are diagnosed with prostate cancer easily be confused with “getting older”. each year in the UK. Because the prostate gland surrounds Ethnicity. African Caribbean men are the tube known as the urethra, which three times more likely to develop passes urine from the bladder to the prostate cancer. outside of the body, any prostate Family history of prostate cancer. disease or growth (benign or Having a brother or father with malignant) is likely to cause problems prostate cancer increases the risk with urination. Men should be aware compared to men with no family of any changes and in particular the history of the disease. If a close following: member of the family was diagnosed with prostate cancer under the age of 60 the risk is much higher. Slow or weak flow of urine Family history of breast cancer. Urinating more frequently or urgently than usual The risk increases slightly in men who have a strong family history Difficulty starting to urinate of female breast cancer and vice versa (National Cancer Institute). Pain or burning sensation when urinating This is thought to be because two genes carried by both men and Difficulty getting or maintaining an women (called BRCA1 and BRCA2) erection or pain during ejaculation. increase the risk of breast cancer in Less common symptoms women and prostate cancer in men include the following: (Cancer Research UK). Unexplained urinary infection Diet. A diet high in saturated or pain in the groin, back or hips fats and red meat may lead to an increased risk of developing cancer Blood in the urine or semen including prostate cancer. Impotence Constipation, altered bowel habit, or not feeling the bladder is completely empty.

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 In addition EGGS - 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 test for prostate cancer as levels can be high in people who do not have the diagnosed? condition. Having a PSA test can be very Two tests are commonly used by the GP reassuring if it is normal and, importantly, for the initial investigation of prostate- can help find some cancers at an early type symptoms: stage. Unfortunately, the PSA test does A digital rectal examination (DRE), miss some prostate cancers and it can which is quick and simple to perform, lead to unnecessary worry and further and involves a GP inserting a gloved, tests in people who are found not to lubricated finger into the rectum (back have cancer. passage) to feel if the prostate gland is For more information on the PSA blood enlarged, or firm and irregular. test please see our fact sheet The PSA A PSA (Prostate Specific Antigen) blood blood test. test, which measures the level of a protein produced by the prostate and is usually elevated in prostate cancer. The PSA test is not a specific diagnostic

10 Prostate cancer can only be diagnosed definitively from samples of tissue ? Q. What is meant by the “grade” and removed from the prostate gland using a and examined under a . “stage” of prostate cancer? People with a strong family history of A. If you are diagnosed with cancer, prostate cancer should be more aware a specialist healthcare team will of the disease especially as there may need to identify the “grade” or be no obvious urinary symptoms in aggressiveness of your cancer and early disease. the “stage” or progression of your cancer in order to determine the If someone is diagnosed with prostate best course of treatment. The cancer the specialist healthcare team “grade” of cancer is determined may carry out additional tests and scans through the biopsy and the system such as an MRI and bone scan to identify used to measure the grade is whether the cancer has spread beyond called the Gleason grading system. the prostate. The results of these scans and the results of the biopsy will be used If the cancer is slow growing, and to give the prostate cancer a T stage non-aggressive, it will have a low where T stands for tumour (see diagram “Gleason score”. If it is fast growing, below). This will help on deciding which at risk of spreading to other parts treatment will be best for the extent of of the body and aggressive, it will cancer present. have a high “Gleason score”. Most cancers will be scored somewhere between 6 and 10. The “stage” of your cancer determines how far, if at all, it has spread.

Bladder Spine Prostate T1 Bladder T2 Rectum

T3 Prostate

T4 Tumour invading other structures

Prostate Cancer 11 Treatment options: Choice of treatment will depend on a large number of factors, and every individual what are they? will be assessed carefully before any There are a number of treatment options treatment decisions are made. A team of currently available and the main ones urologists, oncologists and other health include: professionals called a Multi Disciplinary Team (MDT) will discuss all of the available results at a special meeting and Active surveillance and “watchful make a recommendation for a particular waiting” treatment(s) based on their knowledge Surgery (open, keyhole or robotic and experience. This recommendation will surgery) then be discussed with the patient. The following tables contain a list of treatment Radiotherapy options, when they are used and the Hormone therapy 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 with PSA tests, DREs and waiting to see usually further 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 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. There are many types of surgery including or urinary “open”, keyhole (laparoscopic) and robotic. No incontinence. 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 can encourage growth of prostate become immune cancers. It is usually very effective at, and other regressing and controlling prostate cancer but treatments may does not cure the disease. be 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 ? There are many new treatments for Q. What are clinical trials? prostate cancer under development A. Some people with cancer may be and these include: considered for a clinical trial during their course of their treatment. High-intensity focused ultrasound These trials are an important part (HIFU). HIFU is a treatment that of the cancer research process. uses ultrasound (high-energy sound Your healthcare team will discuss waves) to destroy cancer cells. It is the treatment with you so that currently used as a treatment for you have full understanding of the prostate cancer that has returned trial and what it involves. Individuals following radiotherapy but is also who take part in a clinical trial may being evaluated for treatment receive the standard treatment as an alternative to surgery or for their cancer or be among the radiotherapy as initial treatment as first to receive a new treatment. a clinical trial in some but not all Many newer treatments are being treatment centres. developed to treat prostate cancer Gene and immunotherapy. Gene and men with more advanced and immunotherapy uses the disease may be asked to take individual’s own immune system to part in trials to evaluate their fight cancer. Substances made by effectiveness. the body or made in a laboratory are used to boost, direct, or restore the body’s natural defences against Treatment options: longer term cancer. The treatment offered to each person will be regularly reviewed and may change over time. For example a specific The specialist healthcare team can treatment may no longer work, there may explain these treatments and others in be unwelcome side effects or a more more detail and advise you if any may be effective option becomes available. The suitable. specialist healthcare team will support people through this process.

Sex and treatment Whether someone decides to remain sexually active during cancer treatment or not is entirely a personal choice and the type of treatment will affect men in different ways. You may wish to talk to your specialist healthcare team if you have any concerns.

14 Penile Cancer

Penile cancer is a rare cancer and affects over 500 men each year. It is usually diagnosed in men over the age of 50 years although men can be affected as young as 30. i Spine Bladder Pubic bone Seminal Vesicle Prostate Rectum Urethra Vas deferens Epididymis Penis Testicle 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 regulated in the body, begin to of skin, known as foreskin which may reproduce uncontrollably. In most cases, be removed in infancy - this is known the growth is slow however in some as circumcision. Inside the penis is the cases, penile cancer grows quickly and urethra, the tube through which urine may spread to other parts of the body. and semen exit the body.

Penile Cancer 15 Possible signs of penile cancer Skin that are associated There is no single symptom to indicate with cancer of the penis include the presence of penile cancer. Common Bowen’s Disease and Erythroplasia signs include: of Queyrat (collectively called “-in-Situ”). If left untreated White or red scaly patches these could lead to cancer, so it is important to see your doctor and Red moist patches of skin receive the necessary treatment. Change in the colour of the skin Skin thickening How is penile cancer Growth, bump or sore. diagnosed? It can be very difficult to recognise the If a man is suffering from any of the signs and symptoms of penile cancer. above it is important that they see Most GPs will never see someone with their GP for assessment. Any abnormal the disease during their lifetime. Many condition on the penis which does not of the symptoms mentioned are also improve after two weeks of prescribed associated with other diseases, some treatment should be investigated by a of which may be sexually transmitted. specialist such as a urologist. If an initial examination or course of treatment does not “clear up” or resolve What are the likely causes of the symptoms within two weeks it penile cancer? is important to seek a referral to a urologist where further investigation can There is no single known cause of penile be carried out. This may include a sample cancer. However, research studies have of tissue (a biopsy) being removed or shown the following may play a role in a circumcision under a local or general penile cancer: anaesthetic. If the tissue is shown to be cancer, a referral to a specialist centre or The human papilloma virus (HPV)| Supra-Network will be made. that causes penile warts also increases the risk of cancer. Two strains HPV 16 and 18 are linked with penile cancer. Penile cancer is less common in men who have had their foreskin removed (been circumcised) soon after birth.

16 laser or freezing cryotherapy (freezing). ? If the cancer affects the foreskin, it may Q. What is a Supra-Network? be possible to treat it with circumcision A. Supra-Network centres are alone. Removal of part or all of the penis designed to treat specialist or rarer is recommended where the cancer has cancers because there is not a spread to a wider area, is large, covers specialist cancer service in every the head of the penis or is near the base hospital in the UK. Guidelines from of the penis. Total removal also known as The National Institute for Health a penectomy is now much less common, and Clinical Excellence recommend as surgeons can usually preserve the that people who are diagnosed penis. Reconstructive surgery is possible with penile cancer are managed to restore the appearance of the penis by a specialist Supra-Network and sometimes it is possible for surgeons centre. At the centre there is a to reconnect certain nerves to provide multi-disciplinary specialist team sensation and blood flow to allow the – depending on which centre you reconstructed penis to become erect. visit this might include surgeons and Lymphadenectomy involves the surgical a plastic/reconstructive surgeon, removal of lymph nodes in the groin area. oncologists, radiologists, clinical This is an option if it is suspected that the nurse specialists, counsellors and cancer has spread beyond the penis. sex therapists. Chemotherapy may be used along with radiotherapy and surgery particularly The specialist healthcare team will carry where the cancer has spread or to out a series of blood tests, examinations ensure it does not return. Chemotherapy and scans (such as a computerised cream may sometimes be used to tomography or CT scan) to identify treat very small, early cancers that are the stage and grade of the cancer and confined to the foreskin and end of whether it has spread beyond the penis. the penis. This will help to determine the best Radiotherapy may be used instead of course of treatment. surgery when someone is not well enough to have an operation or doesn’t Treatment options: want to have surgery. what are they? Photodynamic therapy (PDT) is a new There are three possible types of type of treatment which is being tested treatment available to you: surgery, for treating penile cancer. It uses laser, radiotherapy and chemotherapy. or other light sources combined with a light sensitive drug (sometimes called Surgery is the most common treatment a photosensitising agent) to destroy option for penile cancer. Removing small, abnormal cells. PDT is only available at surface cancers that have not spread specialist centres. can be done through surgery, either by a

Penile Cancer 17 Resources ? For further information and support Q. Why might you be recommended on male cancer, please visit the Orchid or refused a specific treatment? website at www.orchid-cancer.org.uk A. No two cases of cancer are the or call 0203 465 5766. same. The grade and stage of Orchid has produced a series of leaflets the cancer will vary, as will the and Factsheets on specific issues medical history and general health relating to male cancer. You may find the of the person being treated. Your following helpful: specialist healthcare team (MDT) will consider all these factors before Testicular Cancer - all you need to recommending a specific course know booklet of treatment. They will also want Testicular Cancer and Your Fertility to consider the side effects of your treatment and how this might affect Ball Basics - a quick guide to your quality of life. testicular health and testicular cancer Q. What is palliative care? Prostate Cancer and You - a quick A. If the cancer is very advanced or if guide to prostate cancer it has spread to other parts of the body there may be limited or no PSA Factsheet treatment options. In this case the Penile Cancer Booklet and specialist healthcare team will offer Information Leaflets palliative care to help relieve pain or other symptoms. Low-down, Orchid’s newsletter features the latest news and developments in male cancer including research, Sex and treatment treatments, new services and events. The type of treatment will affect men Other helpful websites include: in different ways. Most treatments for www.cancerhelp.org – which offers a broad penile cancer will not affect the ability range of information and support from to have sex but for men who have had Cancer Research UK for everyone affected part or their entire penis removed they by cancer. will find their sex life is affected. Access www.macmillan.org.uk – offers information to specialist support from counsellors or and support for everyone affected by cancer. sex therapists is important both during www.prostatecanceruk.org – Prostate and after treatment. Cancer UK provides support and information to people affected by prostate cancer.

18 i Orchid has a Male Cancer Helpline manned by specialist nurses on Mondays and Wednesdays 10am-5pm 0808 802 0010 or email [email protected]

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 465 5766 prostate and penile. Fax: 0207 600 1155 Established in 1996 by a young Or you can contact Orchid Nurses testicular cancer patient and the oncologist who saved his life, Orchid Tel: 0203 465 6105 works to improve the lives of people email: [email protected] affected by male cancers through References are available on request. a world class research programme, educational campaigns and raising Written and edited by: awareness and an extensive support Orchid Cancer Appeal and service. Orchid Editorial Board September 2014 To be reviewed 2016.

Orchid has a Male Cancer Helpline manned by specialist nurses on Mondays and Wednesdays 10am-5pm 0808 802 0010 or email [email protected]

i ORCHID St Bartholomew’s Hospital London EC1A 7BE T: 0203 465 5766 F: 0207 600 1155 [email protected] www.orchid-cancer.org.uk

Registered in England with the Charity Commission No. 1080540. Company registered in England No. 3963360

Models featured in this brochure are used for illustrative purposes only.