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Prostate and testicular cancer: are you up to date?

The Institute of Cancer Research
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Early diagnosis of both testicular and prostate cancers is vital. It is important that nurses are aware of the symptoms of both and are able to advise their male patients what symptoms they should look out for.

Testicular cancer
Testicular cancer is still relatively rare, 1,600 men are diagnosed every year,(*) although the incidence rate has risen by 70% in the last 20 years and it is the most common cancer in young men aged 20-35.(†)
However, thanks to advances made at The Institute of Cancer Research, testicular cancer is easily treated if caught at an early stage. If diagnosed early enough the recovery rate can be as high as 96%.
Regular self-examination will help men become more aware of the normal feel and size of their testicles so that any abnormalities can be spotted early on.
Men should be encouraged to look out for the following symptoms:

  • A lump in either testicle.
  • Any enlargement of the testicle.
  • A feeling of heaviness in the scrotum.
  • A dull ache in the abdomen or groin.
  • A sudden collection of fluid in the scrotum.
  • Growth or tenderness of the upper chest.

Self-examination
We recommend that this is done after a warm shower or bath when the scrotal skin relaxes (see Box overleaf). Men should support the scrotum in the palm of their hand and become familiar with the size and weight of each testicle. They should then examine each testicle by rolling it between their fingers and thumb, gently feeling for lumps, swellings, or changes in firmness. Men should be reminded that each testicle has an epididymis at the top, which carries sperm to the penis so, if they feel this it is perfectly normal. If they do feel something out of the ordinary they should be encouraged to go to see their nurse or doctor.

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Next step
A doctor or nurse should carry out a full physical examination. It may be possible for them to tell the difference between a cancerous lump or a lump or swelling due to another cause. However, further tests may be needed and, if the nurse has little experience in this field, they should refer the patient to a specialist. An ultrasound scan may also be arranged by the nurse/doctor.
The only way to confirm that it is cancer is to do an orchidectomy, removing the testicle. The cells will then be examined to see if it is cancerous and if so what type of tumour is present.

Treatments
The tumour will be either a seminoma or a teratoma depending on which cells it contains. There are four stages of testicular cancer:
Stage one: Cancer in the testicle only.
Stage two: Cancer spreads to the lymph nodes in the abdomen.
Stage three: Cancer spreads to lymph nodes in the chest.
Stage four: Cancer spread to other organs.
Treatment will depend on the type of tumour and the stage at which the tumour is at.
For some men the removal of the testicle will be the only treatment needed. However, some men are at a greater risk of the cancer spreading and for them, and where it has already spread, radiotherapy or chemotherapy or a combination of both may be given. This could last for about 3 or 4 months. With all these different treatments men need to have regular check-ups.

Radiotherapy
Radiotherapy is most commonly recommended for men with seminoma. It is usually given daily and the course of treatment lasts between 2 and 4 weeks.

Chemotherapy
There are several cytotoxic drugs used to treat testicular cancer. The two most common are cisplatin and carboplatin, which was developed at The Institute of Cancer Research. These drugs have led to a 96% cure rate if this cancer is diagnosed early.
The patient should then undergo a series of tests to find out if the cancer has spread, as well as blood tests to check if their other organs are working properly, and a chest X-ray to examine the lungs and lymph nodes. Occasionally you may feel that an ultrasound scan, an intravenous urogram or a magnetic resonance imaging (MRI) scan are also necessary to check if the cancer has spread.

The future
Following treatment for testicular cancer it is likely that the patient's fertility and sex life will return to normal.
If he has a testicle surgically removed, he should be given the option of having a prosthetic replacement fitted. The remaining healthy testicle tends to be able to produce enough sperm to compensate for the loss.
 
Prostate cancer
Over 20,000 men are diagnosed with prostate cancer each year.(‡) It mainly affects men over 60 but we are hearing of more men over 40 also suffering from this disease.
One of the problems with prostate cancer is that in its early stages it often does not cause symptoms, and hence it goes unnoticed. When symptoms do occur they may include any of the following:

  • Difficulty in urinating.
  • Delays in urinating.
  • A weak stream of urine.
  • Urinating more often than usual.
  • Pain while urinating.
  • Blood in the urine.
  • Pain or stiffness in the lower back and hips.

These symptoms can also be caused by other conditions that are less serious than prostate cancer. However, it is important that men get themselves checked out so that the cause can be diagnosed and any relevant treatment administered.
There are various prostate cancer tests but none of them are conclusive indicators of prostate cancer.

The PSA test
The PSA test (prostate-specific antigen) can be used to screen for early prostate cancer. However, all patients need to be fully informed about this type of test before they go ahead. A raised result does not necessarily mean they have cancer - a positive biopsy is needed to confirm cancer, which will occur in about one man out of every five. If prostate cancer is diagnosed, it is not necessarily life-threatening and curative treatment may not be required - most men diagnosed with early prostate cancer following a positive PSA test would be expected to have slowly growing cancer which should not cause any problems during their natural lifespan.
There is controversy over whether PSA testing should be used in routine screening for prostate cancer. Many medical professionals feel that it would be wrong to introduce national screening in this country because the effectiveness of screening is unproven and the side- effects of treatment can be significant. As a result there is no NHS PSA testing programme as it has not been demonstrated that it leads to an improvement in mortality. Every man over 50 has a right to a PSA test if they request it, but it is important that they are counselled about the limitations of the test and the need for further investigations if the PSA level is raised.

Other tests

Rectal examination
Feeling the size of the prostate - however, an enlarged prostate does not necessarily indicate prostate cancer.

Biopsy
A tiny sample of tissue from the prostate is taken using a probe and the tissue analysed.

Ultrasound
A small probe is inserted in the rectum and a scan taken to show the exact size of the prostate.

Bone scan
To determine whether any cancer has spread to the bones near the prostate.

Treatments
The treatment of prostate cancer is dependent on its stage. For early/localised disease there are a number of options.

Active monitoring
Some prostate cancers are so slow growing that no treatment is needed. Instead, the patient is regularly followed up and a decision about treatment may be made on the basis of a rising PSA level or a change in digital rectal examination.

Surgery
This involves the removal of the entire prostate gland and seminal vesicles with re-anastomosis of the urethra to the bladder neck. The complications of surgery include erectile dysfunction and incontinence. This can range from mild or stress incontinence (4-21%) to complete incontinence (0-7%).(1)

Radiotherapy
Radical radiotherapy is given with the aim of curing the disease. It is usually given daily and the course of treatment will last between 6 and 7 weeks. The short-term side-effects include urinary frequency, poor urinary stream, dysuria, proctitis and fatigue. These effects usually settle within a month of completing the course of treatment. Long-term complications of radical radiotherapy may occur several months or years after treatment and include erectile dysfunction, ­urinary incontinence, diarrhoea and rectal bleeding

Brachytherapy
This treatment involves the insertion of a radioactive seed into the prostate. It is currently only carried out in a few centres in the UK. Urinary frequency, poor urinary stream and urgency are all side-effects of the treatment. Urethral strictures, erectile dysfunction and bowel symptoms similar to those described above may also occur.

Hormone treatment
Hormone therapies such LHRH analogues or anti- androgens are used to help suppress the growth of prostate cancer by reducing the levels of circulating testosterone. These treatments can be used alone or in combination with surgery and radiotherapy. The side-effects of hormone treatments include erectile dysfunction, loss of libido, breast swelling and hot flushes.
Men with prostate cancer that has spread locally beyond the prostate gland are not suitable for radical surgery or brachytherapy, but they may be treated with radiotherapy or hormone manipulation.
Hormone therapies are the main treatments given to men with metastatic disease. Radiotherapy and radioisotopes (eg, Strontium-89) may be given to help control symptoms and chemotherapy agents are the subject of research trials.

*From the Office for National Statistics
†From the Institute of Cancer Research
‡From the Office for National Statistics

References

  1. Selley S, Donovan J, Faulkner A, Coast J, Gillat D. Diagnosis, management and screening of early localised prostate cancer. Health Technol Assess 1997;1(2):1-96.

Resources
If men would like to be sent an information sheet on testicular/ prostate cancer they can call the Everyman Campaign on 0800 731 9468
If they would like to speak to ­somebody about a specific health concern they can call Cancer BACUP on 0800 181199
W:www.cancerbacup.org.uk
For a patient leaflet by The Royal Marsden Hospital, call 020 7808 2831