
Dealing with loneliness; treating testicular cancer: Upstate Medical University's HealthLink on Air for Sunday, Oct. 15, 2023
Psychiatrist Hilary Gamble, MD, talks about the epidemic of loneliness. Urologist Hanan Goldberg, MD, discusses testicular cancer and its spread.
Transcript
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a child and adolescent psychiatrist addresses the nation's loneliness epidemic.
Hilary Gamble, MD: ... 50% of all Americans said that they felt lonely prior to the pandemic. So while I think that the pandemic certainly worsened that sense of isolation and loneliness in our population, I think there was a certain amount of that that predated our pandemic. ...
Host Amber Smith: And a urologist gives an update on testicular cancer.
Hanan Goldberg, MD: ... It's a cancer of young men, usually anywhere between the age of 15 to 35-40, depends what type of cancer. It's a relatively uncommon cancer. ...
Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.
On this week's show, we'll get an update on the detection and treatment of testicular cancer, but first, a psychiatrist discusses why loneliness is on the rise among children and adolescents, and what we can do about it.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Earlier this year, the U.S. surgeon general, Dr. Vivek Murthy, released a report calling attention to the public health crisis of loneliness, isolation and lack of connection. It's something that can affect mental, physical, and societal health in people of all ages.
For help understanding this report, I turned to child and adolescent psychiatrist Dr. Hilary Gamble. She's an assistant professor of psychiatry and behavioral sciences at Upstate.
Welcome to "HealthLink on Air," Dr. Gamble.
Hilary Gamble, MD: Thank you for having me.
Host Amber Smith: The surgeon general had to think this was important, in order to issue an 82-page report called "Our Epidemic of Loneliness and Isolation." Do you think this is all because of the pandemic forcing us to socially distance?
Hilary Gamble, MD: Well, first of all, I'm so glad that we are broaching this topic. I think it's an important one to explore now, and also retrospectively. According to the report, 50% of all Americans said that they felt lonely prior to the pandemic. So while I think that the pandemic certainly worsened that sense of isolation and loneliness in our population, I think there was a certain amount of that that predated our pandemic.
The lockdown loneliness, I think, has been a particular stressor, obviously, and not just in the United States, but worldwide. A recent study in the U.K. presented data that helped us to better understand, I think, the added impact of the lockdown loneliness. And the researchers showed us that there was certainly an increase in the amount of loneliness that people experienced during, and relatively, post-pandemic, I guess you could say at this point. And also there is a certainly an associated decline in mental health.
Host Amber Smith: Well, one of the things that preceded or was out there before the pandemic is social media. How much of that plays into the creation of loneliness and isolation?
Hilary Gamble, MD: So I think social media, definitely, is a tricky subject. I think that it can sometimes facilitate social connection and also definitely detract from our connections between one another.
If we look at the data specifically of our teens, age 13 to 17, 95% of those adolescents are engaged with using social media in one form or another. I think it's become so commonplace in the way we perform our jobs, interact with school, touch base with family and friends who are maybe far apart or across the world. So definitely there have been some advantages.
Americans have reported that they spend roughly six hours a day on digital media, and a third of Americans report being on some sort of digital media almost constantly. You know, I think to say that that hasn't impacted us socially would be remiss. I think the extent of the impact is difficult to fully understand, because again, there are both pros and cons to the use of social media, and so I think in order to fully understand it, we have to dive into how each individual interacts with social media or with digital media in general.
Host Amber Smith: We've heard about growing numbers of kids in adolescence with depression or suicide attempts. Do you think these cases begin with feelings of loneliness that go unrecognized or untreated?
Hilary Gamble, MD: I think in some instances, yes, as someone who sees children and adolescents who present to our emergency department at Upstate, or who follows or sees new consults for kids in our Golisano Children's Hospital, I can tell you subjectively, loneliness, a sense of isolation or even a more general sense of feeling alone or like people don't understand what they're going through, particularly in adolescents, I think can predispose to worsening mental health, for sure. In particular, we know via numerous studies that in teenagers, isolation is a red flag that we child psychiatrists certainly pay attention to when we hear during an interview.
And that is something that perks up our ears and certainly forces us to, I think, more thoroughly explore other symptoms that could be present that could potentially warrant increased interventions in that population.
Host Amber Smith: Is it common for you to hear from your patients that they feel insignificant or, like, they are dealing with the stress of life all alone?
Hilary Gamble, MD: Yes, I think so, particularly for those who have identified of a struggle of some sort, whether it be worries, social worries or performance worries in school, or a sense of feeling down and disconnected. I think that lack of feeling understood by someone else can really exacerbate one's sense of loneliness.
Host Amber Smith: Well, let's talk about what social connections mean and why they matter. But first, what counts as a social connection? Are we talking about family members, or friends and acquaintances, or phone-call conversations? What is a social connection?
Hilary Gamble, MD: I think, boy, that is the question, isn't it? I think anything that enables us to interact with another person counts as a social connection or interaction, and I think because we all have our own individual needs for feeling social connected. It can look really differently from person to person. So I might have less of an innate need to feel connected to other people. I might be able to tolerate loneliness and be less adversely impacted by it than my sister, brother, parent. And they might have higher needs or wishes for social connection.
So I think that it's important, as we study loneliness and identify the impacts, and therefore theinterventions that could be helpful, that we make it individualized, based on one's particular needs and wishes.
Host Amber Smith: Do you think that some people are born to be more socially connected and outgoing, and others are just naturally more reclusive?
Hilary Gamble, MD: I mean we know in child psychiatry that every person is born with a certain temperament. Now, the temperament certainly is not fixed in stone throughout one's life. We all know nature versus nurture here, and I think both elements play crucial roles in the development of a temperament and a personality.
And I think that depending on one's experience in life, whether someone is going through maybe the loss of a loved one or a family illness, or has a chronic medical illness, I think those can really raise the level, potentially, of the need for social connectedness versus someone who perceives things as going fairly well.
Now, that's not to say that people who perceive their lives as being very positive are immune to needing social connection. I don't mean that. I just mean that I think, again, as child psychiatrists, we think about development as a longitudinal entity that sort of ebbs and flows based on developmental level and the needs and the psychosocial stressors in one's life at the time.
Host Amber Smith: There seem to be people, though, who, when they're alone, they feel solitude versus anxiety because they're alone. What can we learn from those who feel the solitude that can help us be more like them?
Hilary Gamble, MD: So I think just like we all have our own temperaments, we all experience loneliness or solitude differently. For some people, I think solitude can be peaceful. Some people enjoy going for those quiet walks in the woods. Other people thrive by being surrounded by other people or animals, life of some sort.
And, again, that need might change. So sometimes we feel really overwhelmed or overstimulated. Maybe we've had a really busy week at work and a lot of demands placed on us. And maybe that would lead to us wanting a little bit of disconnection in order to reset ourselves so that we're ready to have additional connections in the future. So I think the work there is for each of us individually to take the pulse on our own needs and wants at the time, and allow ourselves the space to either seek out a social connection or not, to take some space for ourselves to reset.
Host Amber Smith: Now, what are the risks to physical health in people who are lonely and isolated?
Hilary Gamble, MD: I'm so glad that we're speaking about this topic in particular, and I have to admit that when I read the surgeon general's report, I found some of the statistics staggering. So I do want to just review a few of those, for the folks who are listening today. I think they're very important, and I think they really drive home the impact, the gravity of the situation that we're facing now.
So the surgeon general reported that loneliness is associated with a 26% increase in premature death, so death before we would expect it for a person. Lacking social connection is equivalent to smoking 15 cigarettes per day. And childhood isolation results in increased rates of obesity, hypertension, or high blood pressure, and hyperglycemia, or high blood glucose, blood sugar levels, later in adulthood.
So of course, we've spoken thus far about the direct or more immediate impacts on our mental health, like depression and anxiety symptoms, for example. But this data suggests that not only do we struggle with the mental impacts of isolation and social disconnectedness, but also our bodies physically store that pain and inflammation and can manifest really quite troubling symptoms later in life.
Host Amber Smith: So, do we know yet, do those physical symptoms and diseases disappear if the loneliness dissipates?
Hilary Gamble, MD: I would like to think, yes. I think at this point we're lacking in data to support a strong conviction either way. I think what we know about depression and anxiety so far suggests that the sooner it's treated, the sooner our bodies can return to baseline and be free of that chronic inflammation and stress, the better the long-term health outcomes.
Host Amber Smith: So what do you do to help a child or adolescent who complains about feeling lonely? How do you help them?
Hilary Gamble, MD: I think helping adolescents requires a "village" approach, for sure. You think of adolescents as a time in which teens in general are individuating from their families. And by that, I mean that adolescents at that stage start to form really strong peer relationships. And those relationships tend to strengthen as those with family become a little bit more strained. And this is a totally normal developmental stage and is really helpful later in life when you have to form adult-to-adult peer interactions and relationships.
I think sometimes it's difficult, I would imagine, for parents to stay attuned and present with adolescents during that process because naturally they're being pushed away. So my wish would be for parents to continue to stay present, and I realize that sounds vague. I think staying available and making it clear to the adolescent in words and in action that you will be a consistent presence, regardless of the adolescent's changes, can really provide a sense of security and validation for the child. I think so often kids forget that their parents were also adolescents at one point, and we often hear, you don't know what it's like. You've never been through this." And it's tempting to argue, right? And say, "I was a kid once, too."
But the simple fact is their experience IS different than the parents' experience. And so to validate that maybe it's not harder or easier, but certainly different, I think, can have a profound impact in allowing that child the opportunity to talk through the struggles and for the parent to be available when needed, I think, is most important during that time.
Host Amber Smith: Now, some social connections aren't necessarily positive. I'm thinking about gangs or extremist groups that may manipulate their members. Are you concerned about lonely kids being pulled into groups like that?
Hilary Gamble, MD: So I think that predators -- right? That's what we're talking about -- certainly prey on the feeling of isolation, the feeling that "nobody gets me." And when you're in that lonely spot, you are certainly susceptible to anyone or anything that provides validation or a sense of belonging. And like you're suggesting, a sense of belonging can be a really positive thing for some youth, or it can be horribly negative.
And I think that, unfortunately, with social media, we have so many outlets for people with malintentions to reach youth and to pose as people who are superficially supportive but really have an ulterior motive. So I think the isolation is scary.
I give parents a prescription to be extra annoying when I fear that a child or adolescent is isolating or pulling away from social connections, whether it be with friends or family. And I tell the parent, when your child gets angry at you for knocking on their door, checking in, you just blame me. I'll take it. So I invite them to check in more often and to be present because that certainly will decrease the likelihood of their child being a victim.
Host Amber Smith: Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more of our talk about loneliness with Upstate child and adolescent psychiatrist Dr. Hilary Gamble.
Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith, and I'm talking about loneliness and isolation with child and adolescent psychiatrist Dr. Hilary Gamble.
Let me ask you a little more about advice you have for children and adolescents and their parents if they're struggling with feelings of loneliness. Are there bad habits that encourage loneliness?
Hilary Gamble, MD: I think sometimes the process is insidious, meaning we don't notice it until it's a problem. It seems to be kind of inching along, and then all of a sudden families get to a point where they notice they're disconnected from their child, or vice versa. And some of my work with children and families is to explore that process and wonder how we got to this point and what went awry. And there rarely is a simple answer.
Typically it's, "Well, you know, I wasn't feeling well," or "I had a couple of down days, and so I stayed in my room and I was on my video games more and more, and I snapped at my parents every time they came to check on me." And then the parent didn't want to annoy the child and make it worse. And fast-forward a few days or weeks, and now we're in a position where the child is really truly isolated and involved in who's knows what online, potentially, and parents feeling at a loss as to what to do.
So again, I just say: Stay present. Raising children, as we know, is a marathon, not a sprint, right? And so a few days, a few difficult days of pushing into your teenager's life in a respectful way, I think, can mitigate some of these unfortunate consequences and inadvertent consequences of trying to do the right thing, but backing off when, really, people might need you to be more present as a parent or as a family.
Another thing that we often remind each other of in child psychiatry is this idea -- and it sounds very simple -- but we always say, let's try to meet the family or the child where they're at, meaning not everyone is ready to have family dinner every night. Not everyone is at that point where they can handle that. Sometimes it's a couple of check-ins during the day. Sometimes it's one activity a week. And I think that, again, the individualized approach is important to figure out where the struggle is and therefore where a reasonable intervention might be warranted. And I think we have to be mindful to set the bar at a place where the youth can achieve.
Host Amber Smith: Are medications ever part of it?
Hilary Gamble, MD: Sure. When kids meet criteria for bona fide anxiety or depression or other mental health disorders? Absolutely, medications are a part of our treatment. For the most part and for most disorders that we commonly see in children and adolescents, psychotherapy is a main first intervention, our first-line intervention, we call it.
Sometimes if symptoms are more moderate or severe, we do recommend a combination of psychotherapy and medications, but, of course, the psychotherapy doesn't have side effects, right? Like the medications do. So we like to at least start with that for a period of time to see if we can help the youth explore maybe where some of those blocks are, and come up with techniques to help to better cope with that pain that they're feeling inside.
Host Amber Smith: As a follow-up to what you were saying about family dinner, if the youth is so alienated that they can't bear to be together with their family, do they just eat in their room, or what does the family do for that?
Hilary Gamble, MD: I do have some teens that spend a lot of time in their room. I also see a lot of teens who have, like we said, these very strong friend connections. And sometimes they're spending increasing amount of time at friends' houses with other families, and that's not always a bad thing. So sometimes these other families can have really positive impacts. Sometimes these kids can serve as pseudo older brothers or sisters for their friend's younger siblings.
So there are all these dynamics that we better understand once we hear the story. Because on the surface you might hear, "My son's never home for dinner," or whatever, but we find out that that child has actually made a really strong connection with a great friend in school who has a wonderful family and there are little siblings, and he or she has served as like a wonderful older sibling figure for this family.
So, again, creating the narrative and giving space for that and better understanding the reason for the disconnection and what might be driving it. And, if it truly is disconnection, or maybe just a different relationship, that can be very telling.
Host Amber Smith: Is it helpful to tell someone who complains of being lonely to get out there and volunteer or go join this or that? I mean, just the act of being around people. Is that going to help with the loneliness?
Hilary Gamble, MD: Sure. We have this old adage, right? Just smile and you'll feel better, it naturally takes less energy to smile than it does to frown, and all these kinds of sayings. When people are truly suffering with depression -- now, I'm getting a little bit clinical here -- but when people are truly depressed, they generally lack motivation and the ability to feel that joy. So while it may make you, as the suggester of the activity, feel better, like the person is getting out and doing something, that might not have intrinsic value to the person.
And once people start to recover, we notice actually that the people around them see the improvement first, before the person feels better themselves, which speaks a little bit to what you're talking about here, I think. So, can the activity help? Yes. Physical activity, we know, can certainly lower stress hormones. However, the lack of motivation can stand in the way. And I think we just have to be mindful of the tendency for people who are already suffering to feel guilty about it.
And, like I said, when we set the bar, or we make expectations, the important factor is to make sure that we're setting expectations that the person can achieve so that they build confidence and want to do even more next time. If we set the bar too high, and they don't achieve it, then that actually could really exacerbate the symptoms, right, of feeling like a failure, feeling alone or not heard.
Host Amber Smith: Are there changes to society and the way we live today that you think could help overall with this crisis of loneliness?
Hilary Gamble, MD: Gosh, that's the million dollar question, isn't it? I wish I had a thorough or concrete answer to that. As we spoke in the very beginning of this talk, technology certainly has advantages and disadvantages. I think the balance here is of the utmost importance. So our technology has the opportunity to both augment and detract from our social connection.
We all use it differently, and if nothing else, I hope that maybe after listening to this talk, people are able to have at least an honest dialogue about how they're using digital media, how they're using social media, and are they using it to augment social connectedness or is it potentially detracting from the connectedness that they could feel with others?
Host Amber Smith: Well, Dr. Gamble, thank you so much for making time for this interview.
Hilary Gamble, MD: I appreciate you having me. Thank you very much.
Host Amber Smith: My guest has been Dr. HIlary Gamble. She's an assistant professor of psychiatry and behavioral sciences at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
Signs and symptoms of testicular cancer -- next, on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
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 "HealthLink on Air," 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: This is Upstate's "HealthLink on Air," with your host, Amber Smith.
I'm talking to urologic oncologist Dr. Hanan Goldberg 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.
I'm Amber Smith for Upstate's "HealthLink on Air."
Here's some expert advice from Dr. Elizabeth Asiago-Reddy, the chief of infectious disease at Upstate Medical University. What do adults need to know about the RSV (respiratory syncytial virus) vaccine?
Elizabeth Asiago-Reddy, MD: This is something new that has just come out. There were actually two vaccines that were evaluated in June by the FDA (Food and Drug Administration) one that's made by GSK and one that's made by Pfizer. Those are called Arexvy and Abrysvo, respectively. And they're both highly effective in preventing severe lower respiratory tract infection from respiratory syncytial virus, or RSV.
The GSK Arexvy appears to be slightly more effective when we look at the available data. And it had a unanimous vote of approval, versus a couple of dissenters on the Pfizer vaccine. But both were approved, and both, again, are effective in preventing severe disease and specifically lower respiratory tract disease -- so that means pneumonia -- in adults, age 60 and up.
So these are currently being recommended as a single dose for adults age 60 and up. What we don't know right now, to my awareness, is whether there'll be additional recommendations for others who might have risk for respiratory syncytial virus based on immune compromise. At this point, I'm only aware of the older adult recommendation at this point.
There is a monoclonal antibody available for children, which is new as well. So with these combinations of prevention options, we're hoping that we'll have a less severe RSV season than last year. So last year was a very severe RSV season that was somewhat unprecedented.
For right now there's no contraindication to getting all three vaccines together at the same time -- so that would be flu, RSV and COVID. I would definitely recommend anyone who's eligible asking their primary care provider about all of these vaccines and how best to give them in combination.
It looks like, because the RSV vaccine is adjuvanted -- what that means is that there's a medication put into the vaccine that boosts the immune response. There's a possibility that people might have some more symptoms associated with getting multiple vaccines delivered at once.
That having been said, when reviewing expert advice and realities on the ground, what happens when you split up vaccines is that people oftentimes just don't get them. And so it would be better to get all three, especially for those individuals who are at highest risks, so those include the people in the age groups recommended, and especially those with comorbidities.
Host Amber Smith: You've been listening to Upstate infectious disease chief, Dr. Elizabeth Asiago-Reddy.
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Jillian Barnet is a physical therapist, masseuse and a poet. She sent us a poem that starts off cataloguing the many indignities that cancer can mean for a body. Yet she ends with a beautiful reminder that love can push those moments aside.
Here is "You Don't Need a Nose and Other Things I've Learned":
You don't need a nose, but can do
with something resembling
melted fudge, just don't look
in the mirror. If you make a joke
about your prosthesis on Monday,
it doesn't mean you won't try to kill yourself
by Wednesday. Two eyes are unnecessary
for driving, but your 5-year-old may ask
you to put your second one in
before taking him to school. Men
most often get melanoma
on the back, women
on the leg. Sunscreen
is next to worthless. According
to accountants, it should take
no more than eight
minutes to tell a patient
he's dying. An ear
can be lopped off and
you'll hear fine through the unadorned
hole in your head. It's a very bad
idea to remove your own
melanoma with a kitchen knife. You can get
melanoma where the sun
doesn't shine. If you have
your eye radiated, or removed, you
have equal chances
of survival, but the fake eye will
seem more organic than
the blind one. Polymer
eyeballs bounce and easily
end up in the toilet. If you hated God before
you got stage IV melanoma, you won't
be around long enough to repair
the relationship. Melanoma likes
best to travel to the liver, lungs,
and brain. There are thousands of clinical
trials and no proven treatment. A wedge
of your head can be
removed like a slice of pie with
your cheek and eye in it, and your
husband will still adore you
as he watches you sleep
in your hospital bed. The mind
believes what it must. We are not
our bodies, but longings
individual as clouds.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.
Next week on "HealthLink on Air," some artificial sweeteners cause liver cancer.
If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.
Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.
This is your host, Amber Smith, thanking you for listening.