Uncommon cancer primarily strikes young men, can be cured

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

If testicular cancer has already spread when it's diagnosed, patients tend to have poorer outcomes than when the cancer is found before it spreads.

Doctors know that, but they're curious about what influences the spread of testicular cancer. My guest will go over that with us. Dr. Hanan Goldberg is an assistant professor of urology at Upstate who specializes in urologic oncology.

Welcome back to "The Informed Patient," Dr. Goldberg.

Hanan Goldberg, MD: Thank you. Thanks for having me again.

Host Amber Smith: You and co-authors from Philadelphia and California examined predictors for metastatic testicular cancer patterns in a paper that was recently published in the journal Urology.

What can you tell us about how this team of urologists decided to focus on this topic?

Hanan Goldberg, MD: One of the colleagues, actually the last author of the paper, Dr. Thenappan Chandrasekar, he's a colleague of mine. We actually did fellowship (specialty training) together, and we have published quite a few papers on different aspects of urological oncology, and one of the ideas that we had is kind of to look at this, specifically at metastatic testicular cancer patients, patients presenting with disease that has spread outside the testicle.

And we wanted to see if we can use one of the large databases available, and in this case, we use the SEER (Surveillance, Epidemiology and End Results), which is a large database available for research to see if we can find any kind of predictors or associations with patients that are presenting with a metastatic disease, with disease outside the testicle, and see if maybe we can better treat them by presenting this data, so that's how this idea came to fruition.

Host Amber Smith: So how many men were part of the data set? And are they all from what area of the country?

Hanan Goldberg, MD: The SEER database covers basically the entire country, entire U.S. The percentage changes, but it's about 20-something percent of health care centers around the country.

And we had, I think, more than 16,000 men that we managed to find between the years of 2010 and 2016 with a diagnosis of testicular cancer, and of these men, about 1,800 men had distant metastasis, meaning, again, disease outside of the testicle, at diagnosis.

And we specifically looked at these men. These men represented approximately 11% of our cohort, and we looked at them and tried to see if there's any associations with the fact that they presented with disease outside the testicle.

Host Amber Smith: Well, we'll get into that a lot more, but like many cancers, the prognosis for testicular cancer is better the sooner it's identified, before it has time to spread. With that in mind, can you go over the early symptoms of testicular cancer? Because I'm wondering, these men where it had already spread, did they ignore warning signs?

Hanan Goldberg, MD: So again, testicular cancer, just a little bit of an overview. So it's a cancer of young men, usually anywhere between the age of 15 to 35, 40, depends what type of cancer it is.

It's a relatively uncommon cancer. There's about, in 2023, there's about 9,000 cases that are estimated to be diagnosed, with the estimated death as about 470, so the prognosis actually for testicular cancer is extremely good. It's above 95%. We can reach cure, complete cure, even if it's metastatic disease, which is kind of rare for cancers, but even for metastatic disease, we can reach a cure in over 95% of patients.

Some patients with very bad disease and very high-volume disease that has spread outside the testicle to many places in their body, do have worse prognosis, but even for them, the cure rate is relatively good. It's above 70%, which is quite good when you compare it to other cancers, for instance, pancreatic cancer, bladder cancer and other cancers like that.

For your question, you asked specifically about symptoms. So, usually, there's actually no symptoms at all. It's a cancer that is found usually by men or their doctors palpating a small lump or small lesion on their testicle. And that's why we, and maybe we'll talk about that a little bit later, we are very strong advocates of self-screening, self-testing for men, especially for young men, at least once a month when they're in the shower, after they're done with the shower, just to palpate their testicles and make sure that there's no new lumps or lesions.

But that is really the majority of how these cancers are found. There's sometimes pain, but this is quite rare. It happens, about 15% of cases or 20% of cases, that there is some pain associated, but the majority, 80%, it's just a lump that is felt on examination done by someone.

Host Amber Smith: You said it's seen more in younger men. Are there other risk factors that make someone more susceptible?

Hanan Goldberg, MD: Yes, yes. So, there's a few risk factors that we know about. I think the most important one is what we call undescended testicles. So, the testicles in male babies, they're actually formed during the embryo period in the abdomen, and they make their way all the way down to the scrotum right before birth.

And sometimes what happens is that the testicle actually does not go all the way down where it's supposed to go and actually stays in the abdomen or stays in the groin, kind of stops midway, and that's something that needs to be diagnosed after the male baby is born and needs to be followed and actually needs to be treated, and the recommendation usually is to treat this by the age of 1.

So, if by the age of 1, the testicle has not come down all the way to the scrotum where it's supposed to be, a procedure, which is relatively simple, needs to be done, which is called orchiopexy, which is basically bringing the testicle down to the scrotum and anchoring it there. And we know that if that is not done, the risk for testicular cancer is quite significant. So that is probably one of the biggest risk factors.

Of course, if there's family history of testicular cancer, if there's history of testicular cancer in the same patient in the other testicle, that also puts him at risk for testicular cancer in his remaining testicle. We know that in White men, the risk is higher, about four times higher, most likely, than in Black men. But that's pretty much what we know with respect to ethnicity and race.

But these, I would say, are the major risk factors.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Hanan Goldberg. He's a urologic oncologist at Upstate, and we're talking about testicular cancer.

What do doctors know about what spurs testicular cancer to spread?

Hanan Goldberg, MD: We actually do not know much about that, and we do not know why certain cancers spread more quickly, and certain cancers spread not as quickly.

There's two types of cancers that are important to know. First of all, the majority of cancers of testicular cancer are called germ cell cancers. They're called germ cell because the germ cell is actually the cells that make the sperm, and that's the majority of cancers that are formed in males in the testicles. And they're pretty much divided into two categories, seminomas and non-seminomas. Seminomas are actually a little bit less aggressive and non-seminomas are more aggressive.

There's different types of histologies (tissue structure) that are part of these cancers, which we won't go into because that's a whole discussion by itself. But a lot of the cancers are actually mixed. They have a little bit of both. And they are usually treated as non-seminomas because they have that part, that aspect, of the more aggressive type, of the non-seminoma.

But to answer your question, we do know that certain types of cancers in the non-seminoma group are more aggressive and tend to send metastasis more, like a group called choriocarcinoma or embryonal carcinoma and certain other cancers, which are non-seminomas -- like seminomas, only they're less aggressive, and they tend to less send metastasis outside of the testicle.

Host Amber Smith: So you have to figure out which type of testicular cancer you're dealing with before you can even propose treatment, it sounds like.

Hanan Goldberg, MD: Absolutely, absolutely. So here, we come to the, first of all, to the staging. So once a man finds a lump on himself, or a doctor finds a lump on a testicle, it's very important to first send that man to an ultrasound of the scrotum, of the testicles, to better understand what we're dealing with, because there's other things that can cause lumps or cause enlargement of the testicle, which are actually benign, and this is part of the differential diagnosis always, so a condition called hydrocele, which is just fluid around the testicle, which is almost always completely benign. And that is something that we must differentiate and understand that it's not a testicular tumor. So the ultrasound of the scrotum is critical in that. After we do that, and we physically examine the male and the ultrasound, it's done, and we are quite positive that this is a solid lesion, most likely cancer.

Unfortunately, we cannot do a biopsy in testicular cancer. This is in contrast to many other cancers that we do do a biopsy because the risk of a biopsy here is actually in seeding of the cancer, and that is why we cannot do this. And the treatment is usually by removing the testicle itself, in a surgery that is called orchiectomy.

And as you said before, that is the important first part of taking that testicle out, sending it to pathology, having the pathologist look under the microscope, and telling us exactly what type of cancer this is, so we can better understand what kind of additional treatments, if any, that person may need.

Host Amber Smith: So, does treatment inevitably affect the man's fertility?

Hanan Goldberg, MD: Yes, that is a great question. So, because these are young men, and some of these men, sometimes they're not even married, they don't have children yet, and they plan to bring children in the future. It is very important, and that's something we do on a regular basis, that once we have diagnosed testicular cancer with a very high suspicion, and the man is scheduled to undergo removal of the testicle, we actually have the man undergo sperm banking before, especially if he doesn't have children, or plans to have children in the future, additional children, just to be sure. You can still have children with one testicle in the majority of time, but human beings, we're not symmetrical creatures, so one side is always a little bit stronger than the other, so we never know if we're going to remove the more dominant testicle, and that might cause infertility, like you asked me before.

So, just to be on the safe side, I think it is always important to send these men for sperm banking before the procedure, just that they have some reserves if needed.

Host Amber Smith: Well, getting back to the study that you were involved in, patient characteristics, what did you find that might influence whether cancer spreads?

Hanan Goldberg, MD: What we found is that there's a few categories of things that have been associated with having worse disease at diagnosis with disease outside the testicle. There's disease factors, which are kind of obvious, so, a worse stage of the tumor at diagnosis, what we call the T stage, which is kind of the nomenclature that we use to stage the tumors, how far they've advanced, how big they are. So, of course, the bigger the tumor, the more penetrating it is, the higher the chance to have disease outside the testicle.

As I said, certain histologies were found to be more associated with metastatic disease. Tumor size, something that we call lymphovascular invasion, which means the tumor actually going into the vessels inside the testicle itself. If we see tumors, actually, tumor cells, inside the vessels, inside the bloodstream of the vessels, that's of course a risk factor for disease outside the testicle.

We also found that there's patient-specific associations, including ethnicity, race; so, as I said before, White people, White men, have a higher risk of having worse disease. Socioeconomical status, that is something that we've seen in other cancers as well. The worse your socioeconomical status is, the more likely that you are to present with metastatic disease. That is probably not so much associated with the disease itself, but it's probably associated with being presented to the health care system later than you should have.

Now we come to talk about financial toxicity, access to health care, things that we have seen with other cancers as well. So there's kind of a multitude of things, some of them are disease-specific, and some of them are patient demographic-, socioeconomical-specific, that we found that are more associated with worse disease at presentation.

Host Amber Smith: What did you learn about the patients in the study who died from metastatic testicular cancer?

Hanan Goldberg, MD: We learned that, in general, about a quarter, 25%, of patients with metastatic disease died.

That was predicted by the histology that they have, certain histology of types of cancers. They are risk factors for having more aggressive disease, as I said before, and that is a risk factor by itself for death.

Insurance status, that is part of the socioeconomical status that I talked about before. If you don't have insurance, or you have bad insurance, or insurance that does not cover all the treatments, that is a risk factor by itself for death. And as I said before, socioeconomical, low socioeconomical, status in general was a risk factor for death as well.

Host Amber Smith: Did the authors come up with any suggestions for how to level the playing field with regard to socioeconomic status, things of that nature?

Hanan Goldberg, MD: Yeah, that's a question that we've been debating for quite some time, andit's becoming more and more a topic of discussion in many meetings, professional meetings that we go to, the whole access to health care, financial toxicity, socioeconomical status. In general, we as physicians are not doing a good enough job of identifying these people.

And using whatever resources we have, financial assistance programs, any kind of help that we can get to try to better help these patients in getting a better access to the health care, doing their tests, their scans, when they're supposed to be doing it, helping them with the prescriptions that we're sending them, with the financial aspect of this.

So these are kind of very big words, but the more we talk about this, the more studies like these are being published on this, I think, the more we put this on the agenda, and hopefully we can find some more practical solutions for these patients.

Host Amber Smith: You mentioned removal of the testicle is a treatment when it's diagnosed before it has spread.

Are there other aspects of treatment after the surgery? Or does that usually take care of it?

Hanan Goldberg, MD: Even if it's metastatic disease, that is still a procedure that we need to do. That is the initial procedure. So, even if a patient has been diagnosed with metastatic disease, we usually start with doing an orchiectomy.

It's very rare that we don't do this just to get the histology and to better understand what we're dealing with, and then according to the staging scans, it really depends what we find, and according to those scans, and also we have specific testicular markers in the blood, blood tests that we can do, that also help us a little bit understand how bad the disease is, what the volume of disease is.

So, we have actually a staging system that takes into account the T stage, which is actually from the testicle itself that we remove, the scan results of the body, the chest scans, the abdomen scans that we do usually with CT scans, with CAT scans, and the testicular blood test that we do, the markers, we combine all these together, and we get this staging system that we have. And then we can pretty much say what stage the patient is, and according to that, offer him additional treatments.

I would say that in about 75% to 85% of patients, the orchiectomy is probably the only thing that he will need. So, if the scans are negative, and there's no metastatic disease, most, and that happens in about 75% to 85% of patients, depending on the histology, this orchiectomy is pretty much the only thing the patient will need. And, of course, you will need surveillance later on.

If there is metastatic disease, there's different options that we can offer the patient. There's radiation, there's surgery, additional surgery, and there's chemotherapy, and sometimes a combination of these things.

Host Amber Smith: When it does spread, where does testicular cancer usually appear?

Hanan Goldberg, MD: The most common place is actually the lymph nodes in the retroperitoneum, which is kind of the backside of the abdomen, the posterior aspect of the abdomen, where the big vessels are, the aorta, the inferior vena cava. And the lymph nodes in that area is what we call the primary landing zone of testicular cancer, and that's probably the most common place that testicular cancer can spread to, but it can spread, actually, anywhere: to the lungs, to the liver, to the brain, even to the bone. These are more rare, but it can happen, and that's why we do complete staging scans, as I said before, of the head, of the chest, of the abdomen, of the pelvis, and sometimes even bone scans to make sure the disease hasn't spread there.

Host Amber Smith: For men who survive testicular cancer, what effect does that history have on their future health? Are they more prone to other cancers?

Hanan Goldberg, MD: So, that is also something that in the last few years has been brought up more into the focus. You know, these are young men, they're going to live another 70, 80 years, probably, according to the statistics today. And initially, they need to be followed up because recurrence cancer, of testicular cancer, is something that is important, and we follow these men for several years, at least. Some of them actually undergo many, many scans on a regular basis, to make sure that there's no recurrence, in the retroperitoneum or anywhere else.

We also, of course, examine, physically examine, the other testicle to make sure there's no recurrence in that, because that can happen, too. As we said, that is a risk factor.

Once they are cured, and we've followed them for many years, just because of the treatments that they received, which is the radiotherapy or the chemotherapy, that by itself is a risk factor for additional cancers. We've seen this happen before with men developing rectal cancer, pancreatic cancer, bladder cancer, kidney cancer, because of the radiation, because of the chemotherapy, because of the things that they've received. And that's why it's very important to have a survivorship care plan, that's how we call it for these patients, to follow them on a regular basis, to make sure they don't develop any adverse effects from all the treatments that they receive, from all the scans that they receive, and that they don't develop additional cancers.

Host Amber Smith: Well, Dr. Goldberg, this has been very informative.

Thank you so much for your time.

Hanan Goldberg, MD: Thank you. Thank you again for having me.

Host Amber Smith: My guest has been Dr. Hanan Goldberg. He's an assistant professor of urology at Upstate, where he specializes in urologic oncology.

" The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.