Transcript The challenges for young men diagnosed with Testicular Cancer

Dr Hilary Williams
SpR in Medical Oncology
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Impact life threatening illness
Loss testicle, fertility, sexual function
Chemotherapy
Hospital
Economic/Educational impact
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What are the key survivorship issues in testicular
cancer?
◦ Early problems,
◦ Chemotherapy toxicities,
◦ Late effects
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How do we address these issues while providing
appropriate life-stage support?
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~ 15% of 19-24 TYA group have testicular cancer
Incidence in Europe rising by 10-20% every 5 years
100 - 120 new patients a year at Bristol
Haematology and Oncology centre
All cases from ASWCS network (population 2.1
million) seen and treated in Bristol
Supraregional service for Southwest - MDT
discussion and retroperitoneal surgery (specialist
urology surgery)
◦ Links with Cheltenham, Exeter, and Plymouth
Testicular mass and orchidectomy
Staging CT scan
Metastatic disease
BEP combination
chemotherapy – curative intent
Palliation
Early stage disease
Short course
adjuvant
chemotherapy
Active
surveillance
Retroperitoneal
surgery
Active NCRI clinical trials programme leading to tailored attenuated chemotherapy
schedules and surveillance programmes
e.g. TE111- 1 cycle adjuvant BEP vs. 2 cycles in stage 1 NSGCT
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Body image and sexuality
◦ Orchidectomy primary treatment of testicular
cancer
 “All I want for Christmas is a pair of swinging balls”
 Men surveyed, about prosthesis , about 1/3 accepted
implant, about 1/3 not offered, about 1/3 with a
prosthesis dissatisfied: vast majority felt it was extremely
important to be offered an implant. Rustin et 2004
◦ Hairloss: universal with BEP chemotherapy
 Have men been overlooked? A comparison of young men
and women's experiences of chemotherapy-induced
alopecia. Hilton 2007
 “You lose all your arm hair, you lose your pubic hair and
then your body hair and your leg hair and your toe hair,
everything is completely gone,” said one respondent.
Another likened himself to a “plucked chicken”.
Research needed
 Hospital
◦ Frequent clinic attendance & how to individualise needs
◦ Terrified, isolated and bored in adult inpatient units: “deep
distress”, Grinyer 2006
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Education, employment and financial impact
Relationship with family – loss of independence
Mortality and adjustment crisis
“Young men prefer to suffer in silence” – Institute of cancer
research 2001
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Standard chemotherapy - BEP (bleomycin, cisplatin
and etopside)
~ At 2 years following treatment around 20% men experience
toxicity e.g. peripheral neuropathy and raynaud’s phenomenon,
tinnitus and hearing loss (Fossa 2004)
◦ Genetic polymorphisms linked to cisplatin and bleomycin
toxicities have recently been identified
◦ Future ‘tailored treatments’, identification of risk factors and
useful interventions
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Intensified chemotherapy for relapsed/poor
prognosis disease, including high dose
chemotherapy & autograft
◦ Minimal data on toxicity
◦ Toxicity higher with cumulative dose
• Secondary cancers
◦ 4 cancer registry studies published 2005-2007
◦ Increased risk of solid tumours, including colon, bladder,
pancreas, stomach, lung (e.g. standardized incidence ratio of 2.0
or higher)
◦ Increased risk of leukaemia
◦ Younger patients at higher risk e.g. the earlier the treatment the
higher the risk
◦ High risk group - infra-diaphragmatic radiotherapy and
chemotherapy, develop cancers in treatment field
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Excess cardiovascular disease - ? exact risk
◦ Mechanism - chemotherapy related endothelial damage and
metabolic effects of low testosterone
◦ May be mediated by increased risk of metabolic syndrome
◦ High risk group: those who have received over 850mg cisplatin
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Sperm storage
◦ Advised pre chemotherapy
 “This is not the way it is supposed to happen, conceiving a child
is supposed to be wreathed in hope, not this sad, solitary,
desperate procedure- This was one of the most distressing and
utterly cheerless experiences of my life ” Lance Armstrong 2000
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Paternity following treatment
◦ Post treatment paternity rates ~ 70%, but 48% in high dose
chemotherapy group (Brydoy 2005)
◦ 22% use of assisted conception
◦ Subfertilty or infertility may be present at diagnosis of testicular
cancer- aetiology unknown
Quality of life and sexual function
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Quality of life
◦ ‘Most’ men describe their quality of life as similar to age matched
peers by 2 years following treatment
◦ But survivors do have more sexual problems, and increased risk
of anxiety disorder (young patients at higher risk)
◦ Appropriate tools e.g. mobility score or ability to dress
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Gonadal and sexual function
◦ Low testosterone levels in 10-16%, associated decreased quality
of life: research needed
◦ Common clinical problem, little accurate prospective data,
retrospective questionnaire data conflicting
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Staff education
◦ Help staff understand the very individual, changing and
sometimes unpredictable needs of this patient group
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Assess our service & benchmark others
◦ Are we offering both practical and age specific support
around some of the ‘difficult’ issues (e.g. sperm storage,
reduced fertility and sexual function)
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Rational assessment of late effects
◦ Record and address late effects
◦ Identify who is at most risk (e.g. young age diagnosis and
intensive chemotherapy) and how to intervene (e.g.
smoking)
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Opportunity to
◦ Identify life-stage psychosocial issues and provide
appropriate support during and after treatment
◦ Engage with Survivorship strategies
◦ Focused research on reducing treatment toxicity and
identifying needs & acting on results