Prostate & Testicular Cancer

The gland and the disease. "Prostate cancer is a type of cancer that forms in the tissues of the prostate." The prostate "is about the size of a walnut and surrounds part of the urethra (the tube that empties urine from the bladder)." "Prostate cancer is the most common nonskin cancer among men in the United States." "In the United States, about one out of every eight men will be diagnosed with prostate cancer. Most men diagnosed with this disease do not die from it." Yet "Prostate cancer causes more deaths in men than any other cancer except lung cancer".

Who is at risk. "Older age, African American race, and family history of prostate cancer are the most important risk factors for prostate cancer." "Prostate cancer occurs more often in Black men than in White men. Black men with prostate cancer are more likely to die from the disease than White men with prostate cancer."

Most of it moves slowly — and early disease makes no symptoms. "Because most cases of prostate cancer advance very slowly, if at all, the 10-year survival rate for screen-detected, localized prostate cancer is very high." "Early prostate cancer is generally asymptomatic, and an elevated serum PSA level is often the first indication of malignancy." When symptoms come they look like BPH — trouble starting the stream, frequent urination especially at night, trouble emptying, a weak or interrupted flow — and "These and other signs and symptoms may be caused by prostate cancer or by other conditions." Advanced disease can cause "Pain in the back, hips, or pelvis that doesn't go away." and anemia symptoms.

Grading. "The Gleason score can range from 6 to 10. The higher the Gleason score, the more likely the cancer will grow and spread quickly. A Gleason score of 6 is a low-grade cancer; a score of 7 is a medium-grade cancer; and a score of 8, 9, or 10 is a high-grade cancer." Tissue comes from biopsy — "A transrectal biopsy is the removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate."

What PSA is. "PSA is a substance made mostly by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. The level of PSA may also be high in men who have an infection or inflammation of the prostate or benign prostatic hyperplasia (BPH; an enlarged, but noncancerous, prostate)." So: "There is no level of PSA that reliably guarantees that prostate cancer is present or absent." A value of 4.0 ng/mL or more is "the consensus standard for further prostate cancer evaluation" — further evaluation, not an automatic biopsy.

What moves the number (nursing: timing of the draw). "Prostatitis, a digital rectal examination, hard bowel movement, urologic instrumentation, and recent ejaculation can all increase PSA levels." In the other direction, "5-Alpha reductase inhibitors (5-ARIs) reduce PSA levels by 50%, but this effect typically takes between 6 and 12 months. PSA levels in men on long-term 5-ARI medications should be doubled for screening purposes."

The USPSTF owns the screening rule. "For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one." Men "should have an opportunity to discuss the potential benefits and harms of screening with their clinician", and "Clinicians should not screen men who do not express a preference for screening." For older men: "The USPSTF recommends against PSA-based screening for prostate cancer in men 70 years and older." These are the 2018 USPSTF grades — C for 55 to 69, D for 70 and older — and the USPSTF page now shows "Update in Progress for Prostate Cancer: Screening", so check for a newer statement. The digital rectal exam is not a screening test: "The use of digital rectal examination as a screening modality is not recommended because there is a lack of evidence on the benefits".

Why it is a trade-off. Benefit: screening in men 55 to 69 "may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened." But "Current results from screening trials show no reductions in all-cause mortality from screening." and "many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction." NCI: "There is no standard or routine screening test for prostate cancer." For Black men, "the USPSTF is not able to make a separate, specific recommendation on PSA-based screening for prostate cancer in African American men."

Watching is a treatment. "Watchful waiting and active surveillance are treatments used for older men who do not have signs or symptoms or have other medical conditions and for men whose prostate cancer is found during a screening test." "Active surveillance is closely following a patient's condition without giving any treatment unless there are changes in test results."

Surgery and radiation carry lasting costs. Radical prostatectomy is "A surgical procedure to remove the prostate" with surrounding tissue and seminal vesicles; "In some cases, the nerves that control penile erection can be saved with nerve-sparing surgery." The USPSTF numbers: "About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence requiring use of pads, and 2 in 3 men will experience long-term erectile dysfunction. More than half of men who receive radiation therapy experience long-term sexual erectile dysfunction and up to 1 in 6 men experience long-term bothersome bowel symptoms, including bowel urgency and fecal incontinence." "Radiation therapy can cause impotence and urinary problems that may get worse with age."

Hormone therapy (ADT) blocks the fuel. "In prostate cancer, male sex hormones can cause prostate cancer to grow." "This is called androgen deprivation therapy (ADT)." Options include orchiectomy and drugs — "Luteinizing hormone-releasing hormone agonists can stop the testicles from making testosterone." Side effects include hot flashes and "impaired sexual function, loss of desire for sex, and weakened bones may occur in men treated with hormone therapy." "Men who are treated with antiandrogen therapy or orchiectomy are at an increased risk of bone loss. In these men, bisphosphonate drugs lessen the risk of bone fracture (breaks)." ADT controls growth; the sources do not describe it as a cure.

The first weeks of an LHRH agonist — tumor flare. The leuprolide label: it "causes increases in serum levels of testosterone to approximately 50% above baseline during the first weeks of treatment. Patients may experience worsening of symptoms or onset of new signs and symptoms during the first few weeks of treatment, including bone pain, neuropathy, hematuria, or bladder outlet obstruction. Spinal cord compression may contribute to paralysis with or without fatal complications." "Closely monitor patients with metastatic vertebral lesions and/or with urinary tract obstruction for new or worsening symptoms." New back pain, leg weakness or urinary retention in a man with vertebral metastases: escalate as for spinal cord compression — see the oncologic emergencies page. Longer term, GnRH agonists "may lead to metabolic changes such as hyperglycemia, diabetes mellitus, and hyperlipidemia", and "Androgen deprivation therapy may prolong the QT interval."

Who. "Testicular cancer is the most common malignancy in men aged 15 to 45 years and represents one of the most common curable malignancies when identified promptly and treated with a multimodal approach." The USPSTF puts the peak slightly younger — "the most common cancer among males aged 15 to 34 years" — and notes it is "relatively rare compared with other types of cancer." Risk rises with an undescended testis ("Cryptorchidism —2–4 fold increase in risk"), a family history, and a previous testicular cancer.

Where it comes from. "Germ-cell tumors are observed to develop secondary to a tumorigenic event in utero that leads to intratubular germ-cell neoplasia." "These cells do not attain invasive potential until after hormonal changes occur during puberty." — which is why the disease appears in young men. Tumors are divided into seminomas and nonseminomas "because they have different prognostic and treatment algorithms."

How it presents. "Testicular malignancy usually presents as a unilateral lump or painless swelling as an incidental finding. Less commonly, testicular cancer presents with pain, with about one-third of the patients having dull pain." NHS: "a lump or swelling in your testicle", "your testicle getting bigger", "your scrotum feeling heavy, firm or hard". Spread can show as back or lower-abdominal pain, cough or breathlessness. "Physical examination findings of any solid intratesticular mass should be considered to be testicular cancer until proven otherwise."

Diagnosis — ultrasound, markers, and never a scrotal biopsy. "Initial evaluation includes history and physical examination, tumor marker assessment, and scrotal ultrasound." NCI: AFP, beta-hCG and LDH "should be measured prior to removing the involved testicle." AFP "is never elevated in pure seminoma or pure choriocarcinoma." Then: "Radical inguinal orchiectomy is both therapeutic and provides tissue for histopathological diagnosis. Trans-scrotal biopsy should not be undertaken due to the risk of local dissemination due to the manipulation of established lymphatic drainage pathways."

Treatment and cure. After orchiectomy, "Tumor staging guides further management with options including active surveillance, chemotherapy, retroperitoneal lymph node dissection, and radiation therapy." "The chemotherapy regimens used commonly are BEP (bleomycin, etoposide, and cisplatin) or EP (etoposide and cisplatin)." "With effective management, the prognosis is excellent with >90% cure rate and >95% five-year survival rate." Even "patients with widespread metastases at presentation, including those with brain metastases, may have a curable disease and should be treated with this intent."

The USPSTF position is plain (2011, Grade D). "The USPSTF recommends against screening for testicular cancer in adolescent or adult men." "There is inadequate evidence that screening asymptomatic patients by means of self-examination or clinician examination has greater yield or accuracy for detecting testicular cancer at more curable stages." "Screening by self-examination or clinician examination is unlikely to offer meaningful health benefits, given the very low incidence and high cure rate of even advanced testicular cancer. Potential harms include false-positive results, anxiety, and harms from diagnostic tests or procedures."

What to teach instead is symptom awareness. The NHS: "It's important to check your testicles regularly so you know what's normal for you. This makes it easier to notice any changes in the size, look or feel of your testicles." Most cancers are found this way — "Most cases of testicular cancer are discovered accidentally by patients or their partners." — and "having awareness about the disease and seeking prompt healthcare evaluation is of utmost importance." So the message is: know what is normal, and report any lump, swelling, heaviness or change promptly — not a monthly screening routine.

The contrast that matters. Cancer "usually presents as a unilateral lump or painless swelling"; torsion "often presents as an abrupt onset of unilateral scrotal pain." "Testicular torsion is caused by the twisting of the blood supply and spermatic cord." "The majority of cases occur in younger patients (< 25 years old) and are usually due to a congenital abnormality of the processus vaginalis."

Time is testicle. "Testicular torsion is a time-dependent diagnosis, a true urologic emergency, and early evaluation can assist in urologic intervention to prevent testicular loss." "Testicular viability significantly decreases 6 hours after the onset of symptoms; hence, early diagnosis is key." "Surgery is the only treatment." Pain may be felt lower down — "There may be associated lower abdominal and inguinal pain, or alternatively, these may be the presenting complaint rather than scrotal pain." — often with nausea or vomiting.

Don’t be reassured by the exam. "the presence or absence of the cremasteric reflex is not as sensitive as once thought", and "The Prehn sign is not reliable for predicting torsion (relief of pain with testicle elevation)." "Therefore, early urologic surgery consultation upon presentation may be critical even in the absence of confirmatory testing."