Testicular Cancer:
Self-Examination, Treatment & Why the Outlook Is So Good

1. What is testicular cancer?

Testicular cancer is a malignant tumour that arises from the cells of the testicle. Measured against all cancers in men, it is rare. But it mainly affects young men: between the ages of about 25 and 45 it is the most common cancer of all.^¹,²

The second, more important point: testicular cancer is one of the most curable cancers there is. More than nine in ten of those affected are cured for good — a large proportion of them with an operation followed by surveillance, and many even when metastases (secondary tumours) are already present. The reason is that germ cell tumours respond unusually well to platinum-based chemotherapy.^²,³

2. Types and stages

More than 90 per cent of all testicular tumours are germ cell tumours. They usually develop from a precursor, germ cell neoplasia in situ (GCNIS), and are divided into two groups that differ in how they behave and how they are treated:^¹

• Seminomas — about half of all germ cell tumours. On average they occur a little later in life, tend to grow slowly and respond very well to chemotherapy and radiotherapy.
• Non-seminomas — a group made up of embryonal carcinoma, yolk sac tumour, choriocarcinoma and teratoma, often mixed. They more often affect younger men and spread earlier; teratomas barely respond to chemotherapy and have to be removed surgically.
• Rare types — for example tumours of the hormone-producing Leydig or Sertoli cells and, in older men, lymphomas in the testicle. These are treated differently.

Even in the least favourable prognosis group a considerable proportion of those affected are still cured — but the chances there are lower, and treatment belongs in an experienced centre.^³

3. Symptoms: what to look out for

• A painless lump or hardening — the classic sign, often noticed by chance in the shower.
• A change in size or consistency — one testicle becomes larger, firmer or irregular.
• A feeling of heaviness or a dragging sensation in the scrotum or groin; only rarely real pain.
• Enlarged, tender breast tissue — some tumours produce hormones that make the breast grow.
• Signs of advanced stages — persistent back pain caused by enlarged lymph nodes, or a cough or breathlessness with lung metastases.

Not every change in the testicle is cancer — most are harmless. Even so, every new change needs to be checked, because only an ultrasound scan can reliably tell them apart.

4. Causes and risk factors

Why testicular cancer develops is not fully understood. It is thought that the course is already set before birth, while the germ cells are developing. Known risk factors are:^¹,⁴

• An undescended testicle in childhood — even if it was corrected surgically.
• Previous testicular cancer — the remaining testicle has an increased risk.
• Family history — testicular cancer in a father or brother.
• Reduced fertility — markedly reduced semen quality is associated with a slightly increased risk.

On the other hand, injuries, cycling, tight trousers, masturbation or a vasectomy are not proven causes. If you have been blaming yourself for any of these, you can let that go.

5. Self-examination and diagnosis

How to check yourself properly

1. After a warm shower: the skin of the scrotum is relaxed then, and the testicles are easy to feel.
2. Each testicle separately: hold it between your thumb and your index and middle fingers and roll it gently back and forth. The surface should be smooth and evenly firm yet elastic.
3. Get to know the epididymis: at the upper back edge there is a soft, comma-shaped structure — that is normal and not a lump.
4. Look out for changes: lumps, hardening, differences in size or consistency. It is normal for one testicle to be slightly larger or to hang lower.
5. Once a month: if you know your testicles, you will notice changes sooner. If something strikes you, have it checked promptly by a urologist — within days, not months.

To put it honestly: whether regular self-examination lowers mortality has not been proven — partly because testicular cancer is often curable even at later stages. That is why there is no general screening programme. But found early often means less treatment. Checking takes two minutes, and it makes particular sense if you have had an undescended testicle.^¹,⁴

The medical assessment

• Physical examination and ultrasound: an ultrasound scan of the scrotum shows whether a change lies in the testicle itself — painless and quick.
• Tumour markers in the blood: AFP, beta-hCG and LDH — before and after the operation. A raised AFP points to a non-seminomatous component.
• Surgery as the diagnosis: if a tumour is suspected, the testicle is removed through an incision in the groin and examined under the microscope. A needle biopsy through the scrotum is avoided because it can spread tumour cells.
• Staging: CT or MRI of the abdomen, pelvis and chest to determine the stage.
• The other testicle: in certain situations, for example if the remaining testicle is small, taking a tissue sample to look for precursors will be discussed.

For the first consultation it is worth making a list of your questions, previous illnesses and all your medicines — see the guide Preparing for a doctor’s appointment.

6. Treatment: surgery first, then depending on the stage

Almost always, the first step is removal of the affected testicle (inguinal orchiectomy). It confirms the diagnosis and is at the same time the first treatment. If you wish, a testicular prosthesis can be inserted — during the operation or later. What happens next depends on the tumour type, the stage and any risk features.^¹,³

Which option suits you is decided by the treatment team together with you. Especially in stage I, the choice between surveillance and short-course chemotherapy is a genuine weighing-up in which your life situation counts. Second opinions are common and worthwhile with testicular tumours; for advanced stages the guideline recommends an experienced centre.^¹

7. Chemotherapy and supportive medicines

Chemotherapy is given in cycles, usually of three weeks each, with infusions on several days, often as an inpatient. The typical strains and what matters:^⁵

• Nausea: cisplatin is one of the agents most likely to cause nausea. To prevent it, you are given a combination, often with ondansetron, dexamethasone and a further agent — on a fixed schedule, not only once nausea sets in.
• Kidneys and hearing: cisplatin can damage the kidneys, the inner ear and the nerves. That is why you need plenty of fluids, checks of your kidney values and a hearing test; report ringing in the ears early.
• Blood count and infections: etoposide and cisplatin lower the white blood cells. A fever during this phase is an emergency for the hospital.
• Hair: hair loss is common and temporary; more in the guide Medications and hair loss.
• Lungs: bleomycin can damage the lungs — smoking increases the risk. Report an irritating cough or breathlessness straight away.

Ondansetron and similar medicines often cause constipation — together with less exercise and a changed diet, it is a real problem on treatment days. Ask early on for a plan to deal with it rather than waiting. Which supportive medicines you take, and when, is always decided by the treatment team — a look at the guide to drug interactions helps you ask the right questions.

8. Follow-up care and late effects

Follow-up care lasts at least five years and is closest in the first two years. It involves a consultation, an examination, tumour markers and imaging, with as little radiation as possible. Its purpose: to find relapses early, while they are still readily treatable — and to recognise late effects of the treatment.^¹,³

• Heart and blood vessels — after chemotherapy the risk of high blood pressure, raised blood lipids and excess weight goes up. Regular check-ups, exercise and a smoke-free life pay off especially well.
• Nerves and hearing — tingling in the hands and feet (polyneuropathy), hearing loss and tinnitus can persist.
• Hormones — testosterone deficiency is possible, especially after chemotherapy or if the remaining testicle is small.
• Second tumours — the risk is slightly increased after chemotherapy or radiotherapy; that is one reason to keep checking the remaining testicle for life.
• Mind and exhaustion — fear of relapse and persistent tiredness are common and treatable; you are entitled to psycho-oncological support.

9. Fertility, sex and testosterone

A healthy remaining testicle is generally enough to produce sufficient testosterone and sperm. Erection, orgasm and desire usually remain unchanged after the operation. Chemotherapy can impair sperm production temporarily or permanently; in many men it recovers over the following years. During chemotherapy and for some months afterwards, reliable contraception is necessary — the hospital will tell you exactly how long.^¹,⁴

Persistent loss of desire, erection problems, lack of drive or hot flushes can point to testosterone deficiency and should be raised — more under erectile dysfunction. If testosterone is replaced, the following applies:

• Use it regularly: gel daily, injections at fixed intervals — fluctuations show up in your mood and energy.
• Do not pass the gel on: after applying it, wash your hands and cover the area; skin contact with a partner or children can transfer the hormone.
• Keep your check-ups: blood count and hormone levels are checked regularly.
• Mention any wish for children: testosterone given from outside suppresses your own sperm production.

10. Everyday life after testicular cancer

• Follow-up appointments are part of the treatment — especially with surveillance in stage I. Keeping appointments and marker values in one place helps over five years.
• Keep checking — the remaining testicle once a month, for life.
• Stopping smoking and exercise — they lower the increased cardiovascular risk after chemotherapy and protect the lungs after bleomycin.
• Document your treatment history — which agents, how many cycles, radiotherapy yes or no. Your GP practice and the anaesthetic team will still need this years later.
• Talk about it — with your partner, friends, a self-help group. Many young men find this hard; it is worth it all the same.

Testicular cancer often strikes men right in the middle of setting out in life — training, career, starting a family. The diagnosis is a turning point, but one with unusually good prospects. Most men return to their normal lives after treatment, with sport, work and often children of their own.

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