testicular cancer

Testicular Cancer

 

Definition

Testicular cancer is a disease in which cancer cells are discovered in one or both testicles. The testicles, also known as testes or gonads, are located in a pouch beneath the penis called the scrotum.

Description

The testicles make up one portion of the male reproductive system. Normally, they are each somewhat smaller than a golf ball in size and are contained within the scrotum. The testicles are a man's primary source of male hormones, particularly testosterone. They also produce sperm.

There are several types of cells contained in the testicles, and any of these may develop into one or more types of cancer. Over 90% of all testicular cancers begin in cells called germ cells. There are two main types of germ cell tumors in men: seminomas and nonseminomas. Seminomas make up about 40% of all testicular germ cell tumors. Nonseminomas make up a group of cancers, which include choriocarcinoma, yolk sac tumors, embryonal carcinoma, and teratoma.

Although testicular cancer accounts for less then 2% of all cancers in men, it is the most commonly seen cancer in young men aged 15 to 35. It is also one of the most curable.

The American Cancer Society estimates that approximately 8,980 new cases of testicular cancer will be diagnosed in American men in 2004. In addition, about 360 men will die of the disease during that year. Although the incidence of testicular cancer is rising, having doubled since 1975, it is still rare. Scandinavian countries have the highest rate in the world. Germany and New Zealand also have high rates. The lowest incidences of testicular cancer are in Asia and Africa.

Causes and symptoms

The exact causes of testicular cancer are unknown. However, there is research showing that some men are more likely to acquire it than others. The risk for testicular cancer is much higher for boys born with one or both of their testicles located in the lower abdomen rather than in the scrotum. This condition is called cryptorchidism or undescended testicles. The lifetime risk of getting testicular cancer is four times higher for boys with cryptorchidism than the risk in the general population. This risk factor remains even if surgery is done to place the testicle back into the scrotum.

Boys born with Down syndrome are also at higher risk of developing testicular cancer, although the reasons for this increased risk are not yet fully understood as of 2004.

There are other risk factors as well. Men who have had abnormal development of their testicles are at increased risk, as are men with Klinefelter's syndrome (a disorder of the sex chromosomes). A family history of testicular cancer increases the possibility of getting the disease. Men infected with the human immunodeficiency virus (HIV), especially those with AIDS, have a higher incidence, as do infertile men. Certain testicular tumors appear more frequently among men who work in certain occupations, like miners, oil workers, and utility workers. There is no conclusive evidence that injuries to the testicles or environmental exposure to various chemicals cause the disease.

Testicular cancer usually shows no early symptoms. It is suspected when a mass or lump is felt in the testes, although a testicular mass does not always indicate cancer and is usually painless.

Symptoms:

• a lump in either testicle (usually pea-sized, but may be as large as a marble or an egg)
• any enlargement or significant shrinking of a testicle
• a sensation of heaviness in the scrotum
• a dull ache in the groin or lower abdomen
• any sudden collection of fluid in the scrotum
• tenderness or enlargement of the breasts
• pain or discomfort in a testicle or in the scrotum

Diagnosis

When a man exhibits symptoms that suggest a possibility of testicular cancer, several diagnostic steps will occur before a definitive diagnosis is made.

History and physical

The physician takes a personal and family medical history and a complete physical examination is performed. The doctor will examine the scrotum as well as the abdomen and other areas to check for additional masses.

Imaging studies

If a mass is found, the physician will likely have an ultrasound performed. Through the use of sound waves, ultrasounds can help visualize internal organs and may be useful in telling the difference between fluid-filled cysts and solid masses. If the tumor is solid, it is most likely cancerous.

Computed tomography as well as ultrasound may be used to diagnose malignant germ cell tumors in undescended testes.

Blood tests

Certain blood tests can be helpful in diagnosing some testicular tumors. Tumor markers are substances often found in higher-than-normal amounts in cancer patients. Some testicular cancers secrete high levels of certain proteins such as alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and enzymes like lactate dehydrogenase (LDH). These markers may help find a tumor that is too small to be felt during a physical examination. In addition, these tests are also helpful in determining how much cancer is actually present, and in evaluating the response to treatment to make sure the tumor has not returned.

Surgery

If a suspicious growth is found, a surgeon will need to remove the tumor and send it to the laboratory for testing. A pathologist examines the testicular tissue microscopically to determine whether cancer cells are present. If cancer cells are found, the pathologist sends back a report describing the type and extent of the cancer. In almost all cases, the surgeon removes the entire affected testicle through an incision in the groin, though not through the scrotum. This procedure is called radical inguinal orchiectomy.

Once testicular cancer is determined, further tests are necessary to find out if the cancer has metastasized (spread) to other parts of the body, and to ascertain the stage or extent of the disease. This information helps the doctor plan appropriate treatment. These tests may include computed tomography (CT scan), lymphangiography (x rays of the lymph system), bone scans, and chest x rays.

Treatment

Staging

One method the cancer treatment team uses to describe the scope of a patient's cancer is the use of a staging system. Testicular cancer is classified using the TNM system. However, in order to simplify and summarize this information, the TNM description can be grouped according to stages.

Stages of testicular cancer:

• Stage I. This stage refers to a cancer found only in the testicle, with no spread to the lymph nodes or to distant organs.
• Stage II. This indicates that the cancer has spread to the lymph nodes in the abdomen, but not to lymph nodes in other parts of the body.
• Stage III. In this stage, the cancer has spread beyond the lymph nodes in the abdomen, and/or the cancer is in parts of the body far away from the testicles, such as the lungs or the liver.
• Recurrent. Recurrent disease indicates that the cancer has come back after it has already been treated. Testicular cancer can come back in the same testicle (if it was not surgically removed) or in some other body part.

Treatment

The treatment decisions for testicular cancer are dependent on the stage and cell type of the disease, as

A cancerous growth on the testicle.

(Illustration by Argosy Inc.)

well as the patient's age and overall health. The four kinds of treatment most commonly used are surgery, radiation therapy, chemotherapy, and bone marrow or stem cell transplantation.

Surgery is normally the first line of treatment for testicular cancer and involves the removal of the affected testicle. This procedure is known as a radical inguinal orchiectomy. Depending on the type and stage of the cancer, some lymph nodes may also be removed at the same time, or possibly in a second operation. This procedure is called a retroperitoneal lymph node dissection, and can be a major operation. Some patients will experience temporary complications after surgery, including infections and bowel obstruction. If both of the testicles are taken out, a man will have no ability to produce sperm cells and will become infertile (unable to father a child). Surgery removing the lymph nodes may cause some damage to nearby nerves, which may interfere with the ability to ejaculate. Men undergoing surgery for testicular cancer may wish to discuss nerve-sparing surgery with their doctor, as well as sperm banking.

Radiation therapy for testicular cancer is delivered from a machine and is known as external beam radiation. One potential problem with this type of radiation is that it can also destroy nearby healthy tissue as well as cancer cells. Other potential side effects include nausea, diarrhea and fatigue. A special device can be used to protect the unaffected testicle to preserve fertility.

Chemotherapy refers to the use of drugs in treating cancer. Since the drugs enter the bloodstream and circulate throughout the body, chemotherapy is considered a systemic treatment. The drugs primarily used in the treatment of testicular cancer are cisplatin, vinblastine, bleomycin, cyclophosphamide, etoposide, and ifosfamide. These drugs are given in various combinations, since the use of two or more drugs is considered more effective than using only one drug.

Since chemotherapy agents can affect normal as well as cancerous cells, several side effects are possible. These side effects include:

• nausea and vomiting
• changes in appetite
• hair loss (temporary)
• mouth sores

• increased risk of infections
• bleeding or bruising
• fatigue
• diarrhea or constipation

Several drugs are available to assist in treating these side effects, most of which will disappear after the treatment is completed. However, some of the chemotherapy agents used during treatment of testicular cancer may cause long-term side effects. These include hearing loss, nerve damage, and possible kidney or lung damage. Another potentially serious long-term complication is an increased risk of leukemia. This is a rare side effect, however, as it occurs in less than 1% of testicular cancer patients who receive chemotherapy. Chemotherapy may also interfere with sperm production. This may be permanent for some, but many will regain their fertility within a few years.

Studies are ongoing to determine whether high doses of chemotherapy combined with stem-cell transplantation will prove effective in treating some patients with advanced testicular cancer. In this treatment, blood-forming cells called stem cells are taken from the patient (either from the bone marrow or filtered out of the patient's blood). These cells are kept frozen while high-dose chemotherapy is administered. After receiving the chemotherapy, the patient is given the stem cells through an infusion. This treatment enables the use of extra large doses of chemotherapy that might increase the cure rate for some testicular cancers.

Preferred treatment plans by stage of disease

Stage I: Stage I seminomas are normally treated with a radical inguinal orchiectomy followed by radiation treatment aimed at the lymph nodes. More than 95% of Stage I seminomas are cured through this method. Another approach is to perform surgery only. Patients are then followed closely for several years with blood tests and imaging studies. If the cancer spreads later on, radiation or chemotherapy can still be used. Stage I non-seminomas are also highly curable with surgery, followed by one of three options. These options include the performance of a retroperitoneal lymph node dissection, two cycles of chemotherapy, or careful observation for several years.

Stage II: Stage II seminomas and non-seminomas are cured in 90% to 95% of the cases. For the purposes of treatment, stage II testicular cancers are classified as either bulky or nonbulky. Nonbulky seminomas (no lymph nodes can be felt in the abdomen) are treated with an orchiectomy followed by radiation to the lymph nodes. Men with bulky seminomas have surgery, which may be followed by either radiation or a course of chemotherapy. Nonbulky Stage II non-seminomas are treated with surgery and lymph node removal, with possible chemotherapy. Men with bulky disease have surgery followed by chemotherapy.

Stage III: Stage III seminomas and non-seminomas are treated with surgery followed by chemotherapy. This produces a cure in about 70% of the cases. Those who are not cured may be eligible to participate in clinical trials of other chemotherapy agents.

Recurrent: Treatment of recurrent testicular cancer is dependent upon the initial stage and the treatment given. This might include further surgery and chemotherapy. Many men whose disease comes back after chemotherapy are treated with high-dose chemotherapy followed by bone marrow or stem cell transplantation.

As of 2004, there is growing evidence that men treated with cisplatin for testicular cancer are at increased risk of coronary artery disease ten years or longer after treatment. In addition, men who have had an orchiectomy followed by external beam radiation therapy have a significantly increased risk of dying from heart disease or a second cancer.

Key terms

Cryptorchidism — Occurs when a boy is born with one or both testicles in the lower abdomen rather than the scrotum. Known also as undescended testicles, it is the primary risk factor for testicular cancer.

Metastatic testicular cancer — Testicular cancer that has spread to other parts of the body.

Radical inguinal orchiectomy — Surgical procedure performed to remove one or both testicles. It is done via a groin incision.

Testicles — Also called testes or gonads, they are part of the male reproductive system, and are located beneath the penis in the scrotum.

Alternative treatment

There are currently no scientifically proven alternative treatments known for testicular cancer. Nothing has been shown to be as successful as conventional treatment. However, some patients may find certain alternative or complementary treatments supportive while undergoing surgery, chemotherapy or radiation. For example, meditation and relaxation exercises may prove effective in reducing nausea and vomiting. Some dietary modifications and nutritional supplements may be helpful in assisting with recovery after surgery. The testicular cancer patient considering alternative treatments should talk it over with members of the cancer care team. They may be able to offer additional information.

Prevention

The main risk factors associated with testicular cancer—cryptorchidism, family history of the disease, and being Caucasian—are unavoidable since they are present at birth. In addition, many men diagnosed with the disease have no known risk factors. Because of these reasons, it is not possible to prevent most incidences of testicular cancer.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD., editors. "Testicular Cancer." In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Nichols, Craig R., et al. "Neoplasms of the Testis." In Cancer Medicine. 5th ed. Hamilton, Ontario: American Cancer Society, 2000.

Periodicals

Mercer, E. S., B. Broecker, E. A. Smith, et al. "Urological Manifestations of Down Syndrome." Journal of Urology 171 (March 2004): 1250-1253.

Muttarak, M., W. C. Peh, and B. Chaiwun. "Malignant Germ Cell Tumours of Undescended Testes: Imaging Features with Pathological Correlation." Clinical Radiology 59 (February 2004): 198-2004.

Nuver, J., A. J. Smit, D. T. Sleijfer, et al. "Microalbuminuria, Decreased Fibrinolysis, and Inflammation as Early Signs of Atherosclerosis in Long-Term Survivors of Disseminated Testicular Cancer." European Journal of Cancer 40 (March 2004): 701-706.

Zagars, G. K., M. T. Ballo, A. K. Lee, and S. S. Strom. "Mortality after Cure of Testicular Seminoma." Journal of Clinical Oncology 22 (February 18, 2004): 640-647.

Organizations

American Cancer Society. 1599 Clifton Road NE, Atlanta, GA 30329. (800) ACS-2345. http://www.cancer.org.

National Cancer Institute. Cancer Information Service. (800) 4-CANCER.

Other

American Cancer Society (ACS). Cancer Facts & Figures 2004. http://www.cancer.org/downloads/STT/CAFF_finalPWSecured.pdf.

Beeson, Dr. Debra. "Commentary: Testicular Cancer Commonly Seen in Younger Men." Cancer News. April 12, 2000. [cited June 19, 2001]. http://www.ontumor.com/cancernews_sm/testicular041200.htm.

National Cancer Institute CancerNet. June 19, 2001. http://www.Cancernet.nci.nih.gov.

The Testicular Cancer Resource Center. June 19, 2001. http://www.acor.org/TCRC.

testicular cancer

a malignant neoplastic disease of the testis occurring most frequently in men between 15 and 35 years of age. An undescended testicle is often involved. In many cases the tumor is detected after an injury, but trauma is not considered a causative factor. Patients with early testicular cancer are often asymptomatic, and metastases may be present in lymph nodes, the lungs, and the liver before the primary lesion is palpable. In the later stages there may be pulmonary symptoms, ureteral obstruction, gynecomastia, and an abdominal mass. Diagnostic measures include transillumination of the scrotum, excretory urography, lymphangiography, and a urine or serum test to evaluate circulating levels of tumor markers. Tumors develop more often in the right than in the left testis. Testis cancers are often curable. Chemotherapeutic agents, used in various combinations, are increasing the survival of patients with testicular cancer. Some of these drugs are actinomycin D, bleomycin, cis-platinum, cyclophosphamide, methotrexate, and vinCRIStine. Early detection by testicular self-examination enhances chances of cure.

testicular cancer

Lance Armstrong tumor, testicular malignancy, testicular neoplasia Oncology The most common cancer in ♂ age 20 to 35, which is curable if treated early; often first identified by its owner as a lump in the testicle, usually noted after an episode of trauma Risk factors Hx of cryptorchidism, mumps orchitis, inguinal hernia during childhood, or previous TC on other side Management Orchiectomy, RT. See Embryonal carcinoma, Germ cell tumor, Seminoma, Testicular lymphoma.

Testicular Cancer

DRG Category:	712
Mean LOS:	3.2 days
Description:	SURGICAL: Testes Procedures Without CC or Major CC
DRG Category:	715
Mean LOS:	6.6 days
Description:	MEDICAL: Other Male Reproductive System Operating Room Procedure for Malignancy With CC or Major CC

The American Cancer Society estimated that in 2013, there were 7,920 new cases of testicular cancer diagnosed and that 370 men died from this disease. The cure rate exceeds 90%, and the 5-year survival rate is 72%. The risk of developing this cancer is 1 in 300.

Testicular cancer is a rare tumor that arises from the germinal cells (cells that produce sperm) of the embryonal tissues and causes less than 1% of all cancer deaths in men. Testicular tumors are classified as seminomas or nonseminomas. Seminomas are composed of uniform, undifferentiated cells that resemble primitive gonadal cells. This type of tumor represents 40% of all testicular cancer and is usually confined to the testes and retroperitoneal nodes. There are two types of seminomas: classical seminomas (occur between the late 30s and early 50s) and spermatocytic seminomas (occur around age 55, grow slowly, and do not metastasize). Nonseminomas show varying degrees of cell differentiation and include embryonal carcinoma (occurs most often between ages 20 and 30, grows rapidly, and metastasizes), teratoma (can occur in children and adults), choriocarcinoma (rare and highly malignant), and yolk cell carcinoma derivatives (most common in children up to age 3 and have a very good prognosis). Sometimes, testicular tumors are “mixed,” containing elements distinctive to both groups.

Causes

Although specific causative factors for testicular cancer are unknown, research findings suggest a connection between the incidence of cryptorchidism (failure of testicles to descend) and testicular cancer. If an undescended testis is noted in a child, orchiopexy (surgical descent of the testes into its normal position within the scrotum) is recommended as soon as possible after birth. Although orchiopexy does not completely eliminate the risk of testicular cancer, it is believed that the sooner after birth orchiopexy is performed, the less chance there is of developing testicular cancer later in life. An increased incidence of testicular cancer has been found in men infected with HIV (seminomas) and men with testicular disorders such as Klinefelter’s syndrome.

Exogenous estrogen has also been linked to testicular cancer. Male offspring of mothers who took diethylstilbestrol during their pregnancy have an increased risk of developing testicular cancer. In addition, patients who have had mumps, orchitis, or a childhood inguinal hernia are also considered to be at higher risk for developing testicular cancer. Maternal infection with Epstein-Barr virus and cytomegalovirus may be associated with increased risk for a male offspring with testicular cancer.

Genetic considerations

Approximately 1% to 3% of men with testicular cancer report a family history of the disease. Brothers of a man affected with testicular cancer are 8 to 10 times more likely to develop the disease, and when a father is affected, his son is 4 times as likely to have the disease as sons of unaffected fathers. There is clearly a familial pattern, and several genes are being investigated. Mutations in the STK11 and KIT genes and deletions at 12q22 have been observed in tumors.

Gender, ethnic/racial, and life span considerations

Testicular cancer most commonly occurs in men ages 15 to 40, but it can affect males from infancy to old age. It is less common in African American and Asian men. The rate of testicular cancer has more than doubled for men with white/European ancestry men in the last 40 years but has not changed for men with African American ancestry. Men with African American ancestry tend to receive treatment later in the course of the disease and, for that reason, tend to have a poorer prognosis.

Global health considerations

The global incidence of testicular cancer is 1.6 per 100,000 males per year. The incidence is three times higher in developed than in developing countries.

Assessment

History

Obtain a thorough health history, particularly about the occurrence of risk factors. Any male born between 1940 and 1971 should be asked if his mother took any drugs to maintain her pregnancy. The earliest sign of testicular cancer is a small, hard, painless lump that cannot be separated from the testicle; it is occasionally accompanied by low back pain. Men often describe a feeling of “heaviness” or “dragging” in the testicles. These symptoms are often mistaken for epididymitis or muscle strain. Tenderness in the breast may also be present. Inquire about back pain, vague abdominal pain, nausea and vomiting, anorexia, and weight loss, which are all findings that suggest metastasis. Only 25% of men experience symptoms related to metastasis prior to diagnosis.

Physical examination

The testes may be enlarged and swollen. A hydrocele or hematocele may be present. A testicular tumor can be distinguished from a hydrocele by transillumination (inspection of the testes by passing a light through its walls): A tumor does not transilluminate, whereas a hydrocele appears red and a normal testicle illuminates clearly. Because the tumor produces estrogen, inspect the patient for gynecomastia.

A testicular examination is accomplished by placing the index and middle finger on one side of the testicle with the thumb on the other side. Digital separation of the anterior testes from the posterior elements, including the epididymis and cord, is performed with care so that the intrascrotal contents can be palpated. A gentle rolling motion enables the examiner to palpate each testicle completely. A normal testicle is egg-shaped and feels smooth and firm but not hard. One testicle may naturally be larger than the other. A change in size or the presence of a lump is considered to be an abnormal finding. With testicular cancer, the lump is generally painless. Also, palpate the surrounding area for the presence of enlarged lymph nodes. Lymphadenopathy, especially in the abdominal and supraclavicular regions, is also found in more advanced disease.

Psychosocial

The diagnosis of cancer at any time is a lifestyle-altering event, but it is particularly disrupting to the young population. Interruption of school or work schedules, financial coverage for medical expenses, transportation to and from scheduled therapies, and child-care issues are a few of the concerns expressed by patients.

Diagnostic highlights

General Comments: Most testicular tumors are found in routine checkups or by self-examination; they often cause no symptoms.

Test	Normal Result	Abnormality With Condition	Explanation
Scrotal ultrasound	Normal size, shape, and configuration of the testicles	Solid, malignant mass is identified	Noninvasive visualization of the testicles
Radical orchiectomy, followed by a biopsy	NA	Solid mass is removed, 100% prove to be malignant	Needle biopsy would lead to open spread of the cancer cells, thus the biopsy is done after the testicle is removed

Other Tests: Serum laboratory analysis of beta-subunit human chorionic gonadotropin and α-fetoprotein, lactic hydrogenase, complete blood count, chest x-ray or computed tomography (CT) for lung metastasis, abdominal and pelvic CT or magnetic resonance imaging to check for retroperitoneal lymph node metastasis, intravenous pyelography to check for urinary tract involvement

Primary nursing diagnosis

Diagnosis

Pain (acute) related to inflammation, tissue damage, tissue compression, or nerve irritation from tumor metastasis in the perineum, groin, or abdomen

Outcomes

Pain control; Pain: Disruptive effects; Well-being

Interventions

Analgesic administration; Pain management; Meditation; Transcutaneous electric nerve stimulation (TENS); Hypnosis; Heat/cold application

Planning and implementation

Collaborative

surgical.

The initial treatment for testicular cancer is surgical resection of the involved testicle (orchiectomy). A testicular prosthesis can be placed if the patient so desires. If a bilateral orchiectomy is performed, the patient may need hormonal replacement. It is controversial whether or not the retroperitoneal nodes should be resected or treated with chemotherapy. Surgical resection carries with it the likelihood of impotence. To preserve fertility, nerve-sparing retroperitoneal lymph node surgery protects the nerves and allows for normal ejaculation.

Postoperatively, edema and intrascrotal hemorrhage are the two most common problems. Monitor the patient closely for swelling and bleeding. Elevate the scrotum on a rolled towel and apply ice to assist with discomfort and decrease swelling. Observe for signs of infection. Encourage the patient to wear an athletic supporter during ambulation to minimize discomfort. Usually, the patient is encouraged to do so within 12 hours of surgery.

radiation and chemotherapy.

Depending on staging of the disease, radiation or chemotherapy may also be used. Tumors classified as seminomas are especially radiosensitive. External beam radiation is usually given after surgery if the peritoneal lymph system is disease-positive or if the pelvis and mediastinal and supraclavicular lymph nodes are involved. Inform the patient that although the unaffected testicle is shielded during radiation, it does receive some radiation that is scattered, which may decrease spermatogenesis. Nonseminomatous tumors are not radiosensitive, and chemotherapy is the preferred treatment.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Cisplatin	20 mg/m2 per day IV for 5 days/cycle	Antineoplastic, alkylating agent	Increases the long-term survival rate when any type of metastasis is found
Vinblastine	Individualized using white blood cell count as guide	Antineoplastic, plant alkaloid	Most effective at treating metastasis when given in combination
Etoposide	50–100 mg/m2 per day for first five days	Antineoplastic, miscellaneous	Used in combination
Acetaminophen/NSAIDs; opioids; combination opioids/NSAIDs	Depends on the drug	Analgesic	Analgesics used are determined by the severity of pain; pain may be postoperative or caused by metastasis

Independent

Nurses can play a role in the early detection of testicular cancer. Patients should be taught how to do a testicular self-examination and should be encouraged to perform the examination monthly. Provide private time for the patient and his partner to ask questions, express concerns, and clarify information. Offer the patient an opportunity for sexuality and fertility counseling after discussing the impact of the surgery on his anatomy and function. Make sure the patient understands the need to perform coughing and deep-breathing exercises to limit pulmonary complications. Before surgery, instruct the patient on the use of an incentive spirometer.

Because stomatitis is a common occurrence, check the mouth regularly for open irritated areas and encourage the patient to use warm mouthwashes. If the patient becomes nauseated, offer small, frequent feedings and eliminate any noxious stimuli such as bad odors. In addition, have the patient drink at least 3 L of fluid per day to ensure adequate hydration. If the patient is receiving radiation, monitor for side effects. Avoid rubbing the skin near the site of radiation to prevent discomfort and skin breakdown.

Ask about pain regularly and assess pain systematically. Believe the patient and family in their reports of pain. Inform the patient and family of options for pain relief as proposed by the National Cancer Institute (pharmacologic, physical, psychosocial, and cognitive-behavior interventions), and involve the patient and family in determining pain relief measures. To manage the discomfort of chemotherapy in addition to medications, consider the use of biofeedback or other alternative relaxation techniques.

The diagnosis of testicular cancer is a devastating one to most men. Discuss the patient’s concerns with him. Explain the role of hormonal replacement in maintaining the secondary sex characteristics. If the patient is at risk for sterility, explain sperm banking procedures before treatment if infertility and impotence may result from surgery. Refer the patient to a support group or ask that another man who has experienced a similar diagnosis and treatment share his experiences to provide support. If the patient or partner is struggling to cope with the diagnosis, arrange for a counselor.

Evidence-Based Practice and Health Policy

Fossa, S.D., Cvancarova, M., Chen, L., Allan, A.L., Oldenburg, J., Peterson, D.R., & Travis, L.B. (2011). Adverse prognostic factors for testicular cancer-specific survival: A population-based study of 27,948 patients. Journal of Clinical Oncology, 29(8), 963–970.

• Investigators examined mortality rates among 27,948 men diagnosed with testicular cancer and found the 10-year cumulative mortality rate was 3.8% (95% CI, 3.6% to 4.1%).
• Mortality was higher among men with nonseminoma testicular cancer (6.6%; 95% CI, 6.1% to 7.1%) compared to men with seminoma testicular cancer (1.7%; 95% CI, 1.5% to 2%). Nonseminoma testicular cancer was present in 42.5% of men, and seminoma testicular cancer was present in 57.5% of men.
• When comparing married men to unmarried men, mortality among cases of nonseminoma testicular cancer was 1.54 times more likely among unmarried men (95% CI, 1.3 to 1.82; p < 0.001), and mortality among cases of seminoma testicular cancer was nearly three times more likely among unmarried men (95% CI, 2.24 to 3.94; p < 0.001). Half of men in this sample were married compared to 41% of men who had never been married.
• Among men with nonseminoma testicular cancer, treatment with retroperitoneal lymph node dissection was associated with an 86% decreased likelihood of mortality at 10 years (95% CI, 0.08 to 0.22; p < 0.001). Among men with seminoma testicular cancer, radiotherapy treatment was associated with a 68% decreased likelihood of mortality at 10 years (95% CI, 0.25 to 0.45; p < 0.001).

Documentation guidelines

• Physical findings: Operative incisions, patency of intravenous lines, healing of incisions, vital signs, testicular assessment findings
• Response to treatments: Side effects from medications or radiation therapy; management and control of symptoms
• Presence of complications: Infection, bleeding, respiratory distress, unrelieved pain or nausea

Discharge and home healthcare guidelines

medications.

If hormonal replacement is ordered, be sure the patient understands the dosage, schedule, actions, and side effects of the medication.

prevention.

Have the patient demonstrate a testicular self-examination before leaving the hospital. The patient should understand that testicular cancer can recur in the remaining testes and that early detection is a critical factor in the outcome.

sexuality.

Inform the patient that if a unilateral orchiectomy was performed, he is still fertile and should not experience impotence. Make sure the patient understands that he has the option of undergoing reconstructive surgery and placement of a testicular prosthesis. Refer the patient to the American Cancer Society to assist with obtaining information and support.

home care.

Teach the patient to do the following:

• Avoid prolonged standing because this can increase scrotal edema.
• Wear an athletic supporter or snug-fitting undershorts until the area is completely healed.
• Avoid heavy lifting for 4 to 6 weeks.
• Take a 20-minute tub bath three times a day for 1 week after discharge.