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The challenges for young men with Testicular Cancer. Dr Hilary Williams SpR in Medical Oncology. World of young adult. Impact life threatening illness Loss testicle, fertility, sexual function Chemotherapy Hospital Economic/Educational impact. How can we enable healthy Survivorship ?. - PowerPoint PPT Presentation
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The challenges for young men with Testicular
CancerDr Hilary Williams
SpR in Medical Oncology
Impact life threatening illness Loss testicle, fertility, sexual function Chemotherapy Hospital Economic/Educational impact
World of young adult
What are the key survivorship issues in testicular cancer?◦ Early problems, ◦ Chemotherapy toxicities, ◦ Late effects
How do we address these issues while providing appropriate life-stage support?
How can we enable healthy Survivorship?
~ 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
Bristol Supraregional germ cell service
We cure > 95% of men with testicular cancer
Testicular mass and orchidectomy
Staging CT scan
Metastatic disease
BEP combination chemotherapy – curative intent
Early stage disease
Short course adjuvant
chemotherapy
Retroperitoneal surgery
Active surveillance
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
Palliation
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”.
Early problems – unmet and unknown (1)
Research needed Hospital
◦ Frequent clinic attendance & how to individualise needs◦ Terrified, isolated and bored in adult inpatient units:
“deep distress”, Grinyer 2006 Education, employment and financial impact Relationship with family – loss of independence Mortality and adjustment crisis
Early problems – unmet and unknown (2)
“Young men prefer to suffer in silence” – Institute of cancer research 2001
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
Intensified chemotherapy for relapsed/poor prognosis disease, including high dose chemotherapy & autograft ◦ Minimal data on toxicity ◦ Toxicity higher with cumulative dose
What do we need to tell men about chemotherapy related toxicity?
• 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 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
Late effects – emerging data (1)
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
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
Late effects – emerging data (2)
Quality of life and sexual function 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 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
Late effects – emerging data (3)
Staff education ◦ Help staff understand the very individual, changing and
sometimes unpredictable needs of this patient group 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)
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)
The way forward: lets work with our patients
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
Teenage young adult cancer service- spring board to change