Testicular Cancer: Epidemiology, Assessment and Management

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Aim and intended learning outcomes

The aim of this article is to summarise the epidemiology, diagnosis and treatment of testicular cancer. It outlines the pivotal role that nurses play in the management of the disease, from raising awareness and promoting self-examination to clinical assessment, treatment and follow-up. After reading this article you should be able to:

* Identify men at higher risk of developing testicular cancer.

* Describe the clinical signs and symptoms of testicular cancer.

* Explain the testicular self-examination (TSE) technique and the benefits of regular examination in the early detection and treatment of testicular cancer.

* Assist in raising awareness of the disease and promoting self- examination among male patients.

* Summarise the key treatments for testicular cancer and the overall management of the patient.

* Recognise the need for psychological support relating to body image and fertility for male patients following orchidectomy.

Summary

Testicular cancer is the most common type of cancer in men aged 15 to 44 years. This article discusses the causes, diagnosis and treatment of the disease.

Key words

* Men’s health

* Patients: psychology

* Self-examination

* Testicular cancer: prevention and screening

These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.

Introduction

Cancer of the testis is a malignant tumour, which mainly affects young and middle-aged men in their reproductive years (Adami et al 1994). It is a relatively rare disease in the UK compared with other cancers. Approximately 1,900 new cases are diagnosed every year, accounting for fewer than 2 per cent of all male-registered malignant neoplasms (Cancer Research UK (CRUK) 2002). However, the incidence rate has more than doubled over the past two decades and it is the most common cancer among men aged 15 to 44 years (CRUK 2002). Approximately half of all cases in the UK occur in men under 35 years of age (CRUK 2002). The reason for the recent rise in cases is uncertain, although environmental oestrogenic compounds that affect embryonic testis (Sharpe and Skakkebaek 1993) and improvements in cancer registration (Forman and Moller 1994) have been postulated as contributory factors.

In contrast to the increasing incidence, mortality associated with testicular cancer has sharply declined. Advances in treatment options, particularly combined chemotherapy (Newlands et al 1983), have improved the likelihood of survival – demonstrated by a 50 per cent reduction in death rates over the past 20 years (Toledano et al 2001). Cure rates for testicular cancer are relatively high – in excess of 95 per cent if diagnosed at an early stage, that is, before the cancer metastasises beyond the testicular tissue (Dearnaley et al 2001). However, while the benefits of early diagnosis are clear, evidence suggests that a large proportion of men continue to be unaware of the risk of the disease and less than one in five regularly practise TSE (Katz et al 1995, Khadra and Oakeshott 2002, Moore and Topping 1999, Wardle et al 1994). This knowledge deficit presents a major concern for the timely detection and treatment of testicular cancer, highlight-ing the importance of improving men’s access to information to identify personal susceptibility and aid effective TSE practice.

Histology

Approximately 95 per cent of testicular cancers are germ-cell tumours (GCTs), with the remainder consisting of lymphomas and other histological types arising from interstitial cells (Cook 2000). Testicular GCTs are classified into two broad sub-types:

* Pure seminomas, which arise from cells of the seminiferous tubules and comprise 40 per cent of GCTs.

* Non-seminomas, which make up the remainder. These are sub- divided into four categories:

* Embryonal carcinoma.

* Teratoma.

* Choriocarcinoma.

* Yolk sac tumour.

Non-seminomas tend to occur more frequently in younger men, with a peak incidence in males aged 25-29 years compared to 35-39 years for seminoma (Forman and Moller 1994).

TIME OUT 1

List the symptoms of testicular cancer and compare with the following text.

Signs and symptoms

The most common sign of testicular cancer is a lump in the testicle, which can be painful or painless. Swelling of the testicle, change in the tissue texture, aching, feeling of heaviness in the scrotum and asymmetry within the testis can also occur as the tumour enlarges (Cook 2000, Dearnaley et al 2001) (Box 1). Other symptoms such as haemoptysis, breathlessness and back pain suggest widespread disease and around 10 per cent of men may present with one or more of these (Dearnaley et al 2001).

Disease progression

Testicular cancer may be localised (stage I) or metastatic. Seminomas spread via the lymphatic system, while non-seminomas can metastasise by blood and lymphatic routes (Dearnaley eta/ 2001). The clinical progression of testicular cancer is classified into four stages (Box 2).

Testicular cancer is a highly curable disease. The overall cure rate is currently 80-90 per cent (CRUK 2002), which improves further when diagnosis and treatment are undertaken at an early stage. Five- year survival rates for patients with localised disease are 95 per cent for seminoma and 99 per cent for teratoma (Clark et al 2000). Although the prognosis is poorer for men presenting at a more advanced stage, data illustrate that 90 per cent of men with metastatic disease are alive five years after diagnosis (Clark et al 2000).

Box 1. Signs and symptoms of testicular cancer

Box 2. Staging of testicular cancer

TIME OUT 2

Before reading the next section compile a list of factors that you feel may increase the chance of developing testicular cancer. Then compare your risk factors with the following text.

Aetiology

The causes of testicular cancer are not well understood. However, factors linked to higher risk include a history of undescended testicle(s) (cryptorchidism), family history of the disease, previous experience of testicular cancer and being of white ethnicity (CRUK 2002) (Box 3). The major risk factor is cryptorchidism, which occurs in about 10 per cent of patients (CRUK 2002). Men born with undescended testes have five to ten times the risk of developing the disease compared with those in the general population (Swerdlow et al 1997).

A genetic link is implicated in around one third of patients. Worldwide, the highest incidence of testicular cancer is in northern Europe and the lowest is in Asia and Africa (Parkin et al 1992). Testicular cancer is five times more likely to occur in Caucasian men than those of black origin (Bosl et al 2001). Brothers of men with testicular cancer are six to ten times more likely to develop the disease (Dearnaley et al 2001). Familial lineage is also implicated through the identification of a gene, testicular germ- cell tumour 1 (TGCT1), mapped to chromosome Xq27, which increases susceptibility to testicular GCTs (Rapley et al 2000).

Studies have also associated an elevated risk of testicular cancer with in utero exposure to oestrogen or oestrogenic chemicals (Sharpe and Skakkebaek 1993); inguinal hernia; testicular torsion; post-puberty mumps orchitis (CRUK 2002); high socioeconomic status (Swerdlow and Skeet 1988); and an increase in sedentary behaviour (CRUK 2002). However, results have been inconsistent and further epidemiological research is required.

Barriers to accessing medical assessment

In the UK, men are less likely to access health services and receive health promotion advice than their female counterparts (Baker 2002, Banks 2001, Mills et al 1999). Compared with women, men are half as likely to attend the GP surgery and also present at a more advanced stage of illness (Barton 2000, DeVille-Almond 1998). This underuse of services and information has been confirmed by ‘well man’ and family planning clinic attendance data (Brindis etal 1998, Walsh 1998), and is attributed to a number of physical and social factors, including:

* Machismo – traditional masculine characteristics include being physically and emotionally strong, independent and self-contained (Harrison and Dignan 1999). These characteristics impede the ability to ask for help, show vulnerability and take on health issues (Banks 2001, Doyal 2001, Sharpe and Arnold 2000).

* Inexpressiveness – men’s difficulty in articulating their needs has been highlighted as a major barrier to seeking medical advice (Good et al 1989).

* Inaccessibility – male engagement with healthcare services is restricted by the (Baker 2002, Sweetman 2002):

* Opening hours, which conflict with regular employment activity.

* Female-orientated environment of such services, that is, surgery colour schemes and available literature.

Box 3. Risk factors for testicular cancer

* Fact that they are predominantly staffed by women.

Delays in accessing health services not only have implications for the prognosis and treatment options of the patient, but also affect NHS resources. Men’s reluctance to engage with health services is believed to contribute to their higher rates of mortality and morbidity compared with women (Robertson 1995). Nationally, men ar\e twice as likely to develop cancer than women, and it is the second most common cause of male deaths (Baker 2002).

Research illustrates that a significant number of patients with testicular cancer – about 50 per cent – present with advanced stage testicular cancer (Medical Research Council 1985, Wynd 2002). Inadequate knowledge has been cited as a contributory factor to excessive delays between men finding a potential sign of testicular cancer and seeking medical advice (Rosella 1994, Thornhill et al 1986). Two independent studies highlighted an average interval of 14 weeks between symptom discovery and presentation for medical assessment (Jones and Appleyard 1989, Tavolini et al 1999). Further barriers cited by men for postponing medical consultation include fear of receiving a cancer diagnosis and consequential surgery; anxiety associated with sexually transmitted infection; and guilt linked to sexual behaviour (Brodsky 1999, Gascoigne and Whitear 1999, Moore and Topping 1999, Post and Belis 1980). Such deferral is critical given the poorer prognosis and more severe and invasive treatment associated with advanced stage disease (Dearnaley et al 2001, Proutand Griffin 1984).

Testicular self-examination (TSE)

TSE is the routine assessment and manual palpation of the testicles to detect unusual changes, which might identify testicular disease (Cook 2000). Although the efficacy of TSE has been subject to debate, several authors have promoted its use to increase rates of early cancer detection and as a means of reducing treatment- related morbidity (Dearnaley ef al 2001, Singer etal 1993, Thornhill et al 1986, Wardle et al 1994).

Routine self-examination has not been shown to reduce testicular cancer mortality rates and it has been postulated that it may cause unnecessary anxiety among men (Buetow 1996, Kirk 2000, Morris 1996). However, TSE has been viewed as a valuable and relatively inexpensive method of enhancing male health awareness (Friman and Finney 1990, Moore and Topping 1999, Rosella 1994). All of the known risk factors for testicular cancer are predetermined (Brenner et al 2003), the majority of testicular tumours (95 per cent) are malignant (Javadapour 1980) and evidence to support the correlation between TSE and increased anxiety levels is unsubstantiated (Weist and Finney 1996). Findings from a study by Best et al (1996), which examined the impact of a testicular cancer and TSE training programme on a sample of 1,286 high-school boys, demonstrated that although TSE instruction significantly increased knowledge, anxiety levels remained unaffected.

TIME OUT 3

List three things that you feel are barriers to men practising testicular self-examination and write down the ways in which you feel these may be addressed.

Figure 1. Testicular self-examination technique

Factors affecting testicular self-examination practice Knowledge of testicular cancer risk, potential symptoms and correct TSE procedure is important to performing self-examination (Neef et al 1991, Rosella 1994). Knowledge of testicular cancer is consistently higher among men who regularly practise TSE compared with those who do not (Barling and Lehmann 1999, Moore and Topping 1999, Reno 1988). Insufficient information has been cited as a reason for men not undertaking self-examination (Katz et al 1995, Khadra and Oakeshott 2002). Research with men in the United States and the UK has identified other attitudinal and socio-demographic factors associated with TSE performance. These include:

* Older age (Khadra and Oakeshott 2002, Singer et al 1993, Wardle et al 1994).

* White ethnicity (Khadra and Oakeshott 2002, Wynd 2002).

* Higher educational attainment (Wynd 2002).

* Greater social support and encouragement to practise TSE (Brubaker and Wickersham 1990, Moore et al 1998, Wynd 2002).

* Contact with someone with testicular cancer (Khadra and Oakeshott 2002).

* Higher perceived susceptibility to testicular cancer (Katz et al 1995, Reno 1988).

* Greater confidence in the ability to self-examine correctly (Barling and Lehmann 1999, Brubaker and Wickersham 1990, Katz et al 1995).

* Exposure to testicular cancer education (Khadra and Oakeshott 2002, Singer et al 1993).

Testicular self-examination technique All men should practise TSE regularly – about once a month – from puberty onwards. It may be pragmatic to advise men to choose a specific day, such as the first day of the month or payday, to help them remember to self-examine. The best time to undertake this procedure is standing up, during or soon after a warm bath or shower, when the scrotal sac is relaxed and changes are easier to feel (Rosella 1994). This allows the individual to become familiar with the usual weight and texture of the testes (Rosella 1994) and detect any abnormalities at an early stage.

Figure 1 illustrates the self-examination technique. Men should roll each testicle in turn between the thumb (on top) and the index and middle fingers (underneath) several times in an S shape to feel for anything that is unusual from the last examination including a lump, hardness or swelling (Box 1). Testicles should be egg-shaped and feel smooth (Pinkowish 2000) with a soft tube, the epididymis, towards the back of each testicle. It is normal to have one testicle that is slightly larger and hangs a little lower than the other, however, this difference should be consistent from one examination to the next (Cook 2000). It is important that any abnormalities detected are reported to the GP without delay.

TIME OUT 4

Now that you have read about testicular self-examination, write a brief summary of how you would explain to a patient why and how to check his testicles.

Testicular cancer education Studies have demonstrated increased TSE performance following education about testicular cancer (Klein et al 1990, Walker and Guyton 1989). Methods used have included the distribution of written literature (Ganong and Markovitz 1987), viewing an educational videocassette (Marsh 1991), verbal instruction (Luther et al 1985) and performing TSE on a prosthetic model (Steffen et al 1994). Research on men’s awareness of testicular cancer and TSE practice has also indicated that 74-90 per cent would welcome further information about the disease and TSE instruction (Moore and Topping 1999, Thornhill etal 1986, Whiteford and Wordley 2003) and if given such advice would undertake self- examination (Neef et al 1991, Reno 1988).

Nurses in all specialties are in an ideal position to inform male patients about testicular cancer and self-examination (Brown 2003, Cook 2000, Whiteford and Wordley 2003). Given the epidemiology of testicular cancer, education needs to start at adolescence and continue throughout the thirties (Brown 2003). There are numerous routes by which information can be conveyed including (Brown 2003, Cook 2000, Whiteford and Wordley 2003):

* Leaflet distribution via A&E, outpatient clinics, general practice and walk-in centre waiting rooms, and repeat prescriptions.

* New patient health checks and well man clinics in general practice.

* Pre-employment screening by occupational health departments, workplace intranet sites and wage slips.

* Secondary school and student health services.

* Workplace and leisure facility changing rooms and toilets.

The use of written and pictorial literature portraying the TSE technique may be particularly beneficial given men’s potential embarrassment, lack of confidential facilities and time limitations (Cook 2000).

TIME OUT 5

Write down the ways in which men could be educated to perform testicular self-examination. Consider how these can be incorporated into your role.

Clinical assessment

Men generally seek medical assistance after finding a testicular lump, enlargement or aching. It is far less common for men to present with lower back pain, which is related to metastases of the para-aortic lymph nodes or breathlessness and haemoptysis which may indicate pulmonary metastases (Dearnaley et al 2001).

Medical staff will examine the testes to discover if the lump is attached to the testes or if it is another non-associated lump such as a hydrocele or hernia. Urgent ultrasound may assist with the diagnosis. Males with a two-week history of orchitis or epididymo- orchitis need urgent referral to a urologist and should be seen within two weeks (Dearnaley et al 2001).

To assist further with diagnosis and establish metastatic disease, blood samples will be taken to investigate for evidence of raised levels of alpha-fetoprotein (AFP) or human chorionic gonadotrophin (HCG), because seminomas secrete HCG but not AFP whereas non-seminomas may secrete either or both. Pregnancy tests can be used as an inexpensive method to establish raised levels of HCG (Dearnaley et al 2001, Pinkowish 2000). These levels will be monitored throughout the treatment to establish prognosis, response to treatment and for follow-up screening. They are measured before orchidectomy and post-orchidectomy until they have reduced to normal levels (Dearnaley et al 2001).

When these initial investigations are complete a patient with a solid intratesticular lump will be immediately referred for inguinal orchidectomy where a diagnosis can be made. A fine needle biopsy of the lump will not be taken because of the risk of metastatic spread or local recurrence (Pinkowish 2000, Poirier and Rawl 2000). It is important to monitor the spread of metastases to other parts of the body. Radiography of the chest, abdomen and pelvis assesses metastatic spread and aids staging. Computed tomography (CT) scans may be used to give a more accurate picture (Dearnaley ef a/2001, Pinkowish 2000). Following orchidectomy, comprehensive discussion with the patient needs to identify the choice of treatment or surveillance to manage the disease (Dearnaley et al 2001). A multidisdplinary approach throughout the process is advocated by the National Institute for Clinical Excellence (NICE) (2002).

Trea\tment by clinical stage

Non-seminoma GCTs spread via the blood and lymphatic system. Treatment for a low-risk stage I non-seminoma GCT requires surveillance only but high-risk tumours may require adjuvant chemotherapy or surveillance (Table 1). A stage Il metastatic non- seminoma GCT with good prognosis will be treated with three courses of chemotherapy. A stage III tumour with an intermediate prognosis will be treated with four courses of chemotherapy and stage IV with a poor prognosis with four to six courses of chemotherapy with referral to an oncologist (Dearnaley et al 2001).

Seminomas metastasise via the lymphatic system. Treatment for a stage I seminoma requires adjuvant para-aortic radiotherapy in addition to orchidectomy. A stage Il metastatic seminoma with good prognosis requires radiotherapy targeting the para-aortic and ipsilateral pelvic nodal areas. Higher-grade stage Il seminomas may require three courses of chemotherapy. A metastatic seminoma with intermediate prognosis requires four courses of chemotherapy and no patients are regarded as having a poor prognosis (Dearnaley et al 2001).

TIME OUT 6

Based on the summary of treatments presented here, draw up a list of issues that the patient might be concerned about with regard to each. Now consider the resources that are available in your clinical area to help explain the treatment and management of side effects or associated problems.

Side effects of treatment

Chemotherapy Treatment for testicular cancer is now successful. However, regimens involving combined chemotherapy with cisplatin can cause short and long-term side effects, which need to be discussed with the patient before treatment. Dearnaley et al (2001 ) report that the patient may experience the following acute symptoms:

* Alopecia.

* Fatigue.

* Nausea and vomiting.

* Neutropenia.

* Sepsis.

Cisplatin may also temporarily damage the auditory and peripheral sensory nerves but this normally resolves within six to 12 months’ post-treatment in most patients (Dearnaley et al 2001). More serious long-term vascular side effects including cerebral vascular accident, thromboembolic disease and myocardial infarction have been reported in men treated with cisplatin-based chemotherapy due to the development of hypertension and hyperlipidaemia (Vaughn et al 2002). Some patients will need to make lifestyle changes following diagnosis. Increased exercise, adjustment to diet and, if required, the addition of medication will reduce hypertension and lipid abnormalities. Patients who smoke should be encouraged to stop and be referred to a smoking cessation programme (Vaughn et al 2002).

Table 1. Treatment of seminomas and non-seminomas following orchidectomy

Chemotherapy with cisplatin has been used for many years to treat testicular cancer and it is generally believed that the risk of developing a dsplatin-linked tumour is low, with the benefits of treatment outweighing the risks (Pinkowish 2000). Leukaemia has been linked to treatment for testicular cancer when etoposide has been included in the therapy regimen. However, this is only relevant in less than 1 per cent of patients (Pinkowish 2000).

Before treatment, many patients will be concerned about their ability to father children as orchidectomy and chemotherapy can cause azoospermia and oligospermia (Dearnaley et al 2001, Vaughn et al 2002). Despite having oligospermia some men have still been able to father children (Stephenson eta/1995). Spermatogenesis is affected by cisplatinbased chemotherapy and the recovery is dependent on several factors including (Vaughn et al 2002):

* Patient age.

* Severity of oligospermia before treatment.

* Cumulative dose of chemotherapy received.

Fertility needs to be discussed with the patient indepth and a decision made whether to bank sperm before treatment begins. Nerve- sparing retroperitoneal lymph node dissection surgery is used to preserve normal ejaculation (Vaughn et al 2002).

Radiotherapy A patient who is exposed to radiation therapy will be at greater risk of developing a secondary solid tumour. Vaughn et al (2002) identify the overall risk at approximately two to three times greater than that of a person the same age in the general population. These are reported as sarcomas and cancers of the genitourinary and gastrointestinal tract (Bokemeyer and Schmoll 1995).

Supporting the patient

Traditionally when the patient has decided to seek help regarding a testicular lump he will usually go to his GP. This route usually means that he will not have contact with a nurse and is reliant on the GP for support. However, the increasing number of walk-in centres and nurse-led clinics mean that there is a greater chance that a nurse may be the first contact.

The patient may feel reluctant to discuss openly why he has attended due to the nature of the condition. Many males will also be embarrassed about discussing their fears and anxieties or may try to hide their feelings from medical and nursing staff. Everyone has experienced embarrassment but it requires significant skill from the nurse to make patients feel at ease, and enable them to discuss their concerns. Patients’ views of an intimate body area will influence their embarrassment when talking to a nurse (Price 2001). Most men who have testicular cancer are young, otherwise fit and healthy and may feel their ‘macho’ image is under threat (Morman 2000).

Following an initial nursing assessment, all patients with a testicular lump will be directed to the GP for urgent review and referral for ultrasound. Many men may not listen to or accept advice that is given to them, so the nurse needs to emphasise the importance of the medical consultation. The patient who has been referred for an urgent appointment with a urologist will be anxious and will have only had his family and close friends for support in the interim period. Males do not generally want to take responsibility for their health, so appear to transfer it to women (Barton 2000).

To prevent further complications, the patient will be treated rapidly and this is where psychological needs may be missed. Most patients will have many questions they want to ask but, unless they are given the opportunity to raise them, they will remain unanswered. Dearnaley ef a/(2001) emphasise the need for high quality information to be accessible to reduce fears and anxieties about treatment and prognosis. This is also a key recommendation by NICE (2002). Clark et al (2000) outline the concerns raised by males who had testicular cancer and believed the disease may threaten their:

* Future health.

* Employment.

* Relationships.

* Sexual performance.

* Fertility.

Secondary care urology teams can include a specialist nurse who may be involved in outpatient clinics. The medical team is concerned with the treatment and removal of the tumour but, given the current climate of target-driven cancer care (Department of Health 2000), other patient needs are in danger of being missed. By failing to address the physical and psychological needs of the patient, there is a danger of treating the condition and not the person. If a patient is referred for urgent orchidectomy this is the ideal time for the specialist nurse to discuss the treatment plan. To deliver information effectively, the nurse requires extensive communication skills and knowledge of the subject, along with written resources to reinforce information (Caress 2003).

The admitting nurse has the opportunity to discuss the surgical procedure with the patient and allow him time to express his fears and anxieties – not only about the diagnosis and impending surgery but also about his future. The nurse should recognise the patient’s needs and organise the appropriate support systems at an early stage (Baker 1997). Remaining up to date with changes in health care is not easy, particularly for nurses who do not specialise in a particular field and need to deal with information on a wide variety of subjects (Caress 2003). Therefore, the patient should be referred to a specialist nurse, if one is available, because he or she has additional skills which may help reduce the patient’s anxieties.

It is important to remember not to overload the patient with information and to consider whether the patient wants to listen to the information being offered to him. Patients might understand and accept information that is given to them, but may decide not to do anything about it (Caress 2003). Patients who receive appropriate pre-operative information and support recover with fewer problems (Martin 1996). Information on followup care needs to be reinforced post-operatively by the nurse to guarantee the patient can understand and comply with treatment after discharge (Beddows 1997).

As the post-operative patient recovers on the ward the surgeon will confirm his diagnosis. A positive diagnosis of testicular cancer will be devastating for the patient. The extent of the disease, and any metastatic spread, will be detected by increased levels of tumour markers (AFP or HCG) in the blood and these will be used to aid diagnosis and manage further treatment. If a decision is made that chemotherapy or radiotherapy is required, the patient will be referred to the specialist oncology team (NICE 2002). The offer of a prosthesis should be discussed with the patient before discharge. This procedure would usually be provided when treatment is complete.

Other than outpatient visits, for example, for a wound check, and routine follow-up appointments, the patient will not usually have further contact with a secondary care nurse unless referred to an oncology team with specialist nurse input. Therefore, access to additional support is important for patients and carers, for example, through national or local voluntary cancer groups or websites (Clark et al 2000, NICE 2004) and the primary care nurse can assist in this process. If there is no local support group the patient should beencouraged to access a website or make contact by phone. Contact details should be available to all nurses in the primary care setting (Box 4).

Box 4. Support groups and websites

Body image is a major concern for many male patients, particularly in terms of how an orchidectomy may affect their relationships and self-confidence. Some men feel that by the removal of a testicle they lose their masculinity and their ability to have sexual relationships. Morman (2000) suggests that men view the possibility of losing a testicle as humiliating and threatening to the male gender role. However, at least clinically, this is not the case. A man’s capability to have an erection, sexual intercourse or orgasm will not change with the loss of one testicle (Shabbir and Morgan 2004) and it is paramount that this message is reinforced with all patients who have testicular cancer (NICE 2002).

TIME OUT 7

Using the information that you have read, write down the issues that you feel the patient may be concerned about following diagnosis of testicular cancer, for example, treatment side effects, and what psychological support can be provided.

Follow-up

Follow-up care with an oncologist, surgeon or both, is vital for the patient with testicular cancer. Regular assessments are required to monitor tumour markers in the blood, chest X-rays, CT scans of the abdomen and a full medical examination with psychological support. This process may continue for several years and may vary depending on the type and stage of the disease (Shabbir and Morgan 2004). During this follow-up period, the patient is observed to detect early signs of relapse and/or development of secondary cancers when salvage treatment can be most effective (Dearnaley et al 2001).

Dearnaley et al (2001 ) suggest that patients with all stage seminomas and stage I non-seminoma GCTs may be discharged an average of five years’ post-diagnosis, although it is recognised that this period may be extended given the 1-2 per cent chance of relapse within ten years. All patients should be made aware that, if the initial treatment fails, there is a variety of salvage treatments available and that there is still a need to perform ongoing monthly TSE (Pinkowish 2000).

Conclusion

Although comparatively rare, cancer of the testis is the most common malignancy to affect men in their twenties and thirties, when they are economically productive and in their reproductive prime. While the majority of risk factors for this disease are predetermined, negating the option of primary prevention, treatment for testicular cancer is highly successful if diagnosed at an early stage.

Nurses can play a key role, not only in educating men about testicular cancer and self-examination – factors crucial to early detection – but also in delivering psychological support to patients and their families. It is therefore imperative for nurses to be sufficiently informed about testicular cancer risk, symptoms, TSE technigue, assessment procedures, treatment regimens and available support services to guarantee the best outcome for patients with this malignancy

TIME OUT 8

Now that you have completed this article, you may like to write a practice profile. Guidelines to help you are on page 56.

NS281 McCullagh J, Lewis C (2005) Testicular cancer: epidemiology, assessment and management. Nursing Standard. 19, 25, 45-53. Date of acceptance: November 25 2004.

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In brief

Author

Jo McCullagh BSc(Hons), MPhil, is senior health promotion specialist, Sefton Health Improvement Support Service; and Gareth Lewis RN, BSc(Hons), is men’s health nurse, South Sefton Primary Care Trust, Liverpool.

Email: [email protected] sefton-pct.nhs.uk

Copyright RCN Publishing Company Ltd. Mar 2-Mar 8, 2005