Chemotherapy for testicular cancer
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate in the bloodstream and can reach cancer cells anywhere in the body.
The drugs most commonly used to treat testicular cancer are bleomycin, etoposide and cisplatin. This combination is known as BEP chemotherapy. Other combinations of drugs are also used depending on the stage of the cancer, or if it’s come back after treatment.
Chemotherapy for testicular cancer is given:
after surgery, to reduce the risk of testicular cancer coming back (known as adjuvant chemotherapy)
to treat testicular cancer that has spread outside the testicle or come back after an orchidectomy
to treat testicular cancer that’s come back after initial chemotherapy.
Adjuvant chemotherapy for men with early (stage 1) NSGCT is normally two cycles of BEP. A cycle usually takes three weeks.
Men with early (stage 1) seminoma are usually given a single treatment with a drug called carboplatin.
If the cancer has spread or comes back during surveillance
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If testicular cancer has spread outside the testicle, or comes back during surveillance you’ll usually need three or four cycles of BEP.
Occasionally, four cycles of EP chemotherapy are given rather than BEP. EP chemotherapy avoids using the drug bleomycin, which may cause breathing problems in men who already have a lung condition.
If testicular cancer doesn’t completely respond to BEP, or comes back again, more intensive chemotherapy is usually given. Some men, depending on the stage of their testicular cancer, are given more intensive chemotherapy straight away.
Some drug combinations that may be used are:
PEI (cisplatin, etoposide, ifosfamide) – this drug combination is also sometimes known as VIP
TIP (paclitaxel, ifosfamide, cisplatin)
VeIP (vinblastine, ifosfamide, cisplatin).
Occasionally, high-dose chemotherapy with stem cell support is given. This may be given as part of a clinical trial.
How chemotherapy is given
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The chemotherapy drugs are usually given as an outpatient by injection into a vein (intravenously). The drugs may be given:
through a thin, flexible tube inserted into a vein in the back of your hand (cannula)
through a plastic line called a central line, which is put into a vein in your chest
through a thin tube inserted into a vein in your arm near the bend of your elbow (PICC line).
Chemotherapy is given in cycles of treatment. A cycle often takes three weeks. If you’re having BEP, you’ll usually spend 3–5 days in hospital as an outpatient, or sometimes you’ll stay overnight.
This is followed by weekly outpatient visits to be given the rest of the treatment. Other combinations of chemotherapy drugs may involve spending more time in hospital and having the drugs more often.
Your doctor or nurse will tell you how many cycles of treatment are planned for you and explain how you’ll be given the chemotherapy.
Chemotherapy drugs can cause side effects, but these can often be controlled well with medicines. Your doctor or specialist nurse will tell you more about what to expect.
Usually most of these side effects improve and go away when your treatment is over.
Lowered resistance to infection (neutropenia)
Chemotherapy can temporarily reduce the production of white blood cells in your bone marrow, making you more prone to infection. This effect can begin about seven days after treatment has been given, and your resistance to infection usually reaches its lowest point about 10–14 days after chemotherapy. Your white blood cells will then increase steadily and will usually return to normal before your next cycle of chemotherapy is due.
You should contact your doctor or the hospital straight away if:
your temperature goes above 38˚C (100.4˚F)
you suddenly feel unwell, even with a normal temperature.
You’ll have a blood test before having more chemotherapy to make sure that your white blood cells have recovered.
Occasionally it may be necessary to delay your treatment if your blood count is still low.
Anaemia (low number of red blood cells)
Chemotherapy can reduce the number of red blood cells, which carry oxygen around the body. A low red blood cell count is called anaemia. This may make you feel tired and breathless. Tell your doctor or nurse if you have these symptoms. You may need to have a blood transfusion if the number of red blood cells becomes too low.
Bruising or bleeding
Chemotherapy can reduce the production of platelets, which help the blood to clot. Tell your doctor if you have any unexplained bruising or bleeding, such as nosebleeds, bleeding gums, blood spots or rashes on the skin. You can have a platelet transfusion if your platelet count is low.
Nausea and vomiting
Your doctor can prescribe very effective anti-sickness (anti-emetic) drugs to prevent, or greatly reduce, nausea or vomiting. If the sickness isn’t controlled, or if it continues, tell your doctor – they can prescribe other anti-sickness drugs that may be more effective.
Feeling tired is a common side effect of chemotherapy, especially towards the end of treatment and for some weeks after it’s over. It’s important to try to pace yourself and get as much rest as you need.
Try to balance this with taking some gentle exercise, such as short walks, which will help. If tiredness is making you feel sleepy, don’t drive or operate machinery.
Your mouth may become sore or dry, or you may notice small ulcers during treatment. Drinking plenty of fluids, and cleaning your teeth regularly and gently with a soft toothbrush, can help to reduce the risk of this happening.
Tell your nurse or doctor if you have any of these problems, as they can prescribe mouthwashes and medicines to prevent or clear mouth infections. If a sore mouth makes eating difficult, you can try replacing meals with nutritious drinks (see our section on eating problems and cancer).
Loss of appetite
Some people lose their appetite while they’re having chemotherapy. This can be mild and may only last a few days. If it doesn’t improve, you can ask to see a dietitian or specialist nurse at your hospital. They can give you advice on improving your appetite and keeping to a healthy weight.
It’s common to lose your hair with chemotherapy treatments like BEP, although carboplatin (used to treat seminoma) doesn’t usually cause hair loss. Your hair will usually start to fall out 3–4 weeks after starting treatment, although it may occur earlier. Hair usually falls out completely. You may also have thinning and loss of eyelashes, eyebrows and other body hair. This is temporary and your hair will start to grow again once the treatment has finished.
Some men shave their heads once they notice their hair is starting to fall out. You can cover up using different hats (like baseball caps and beanies) or with bandanas.
Choose something that suits your personal style and that you’re comfortable with. You’ll probably end up with a variety of things that you can wear depending on the occasion and the weather. Your doctor or nurse can arrange for you to see a wig specialist if you want to use a wig. If you’re an inpatient or are on income support, you can get a free wig from the NHS.
Changes to the lungs
Bleomycin can cause some changes to the lungs. This can happen during treatment or after it has finished. Your doctor can give you information about this potential side effect.
Tell your doctor if you smoke, or if you notice any wheezing, coughing or breathlessness. You’ll probably have a chest x-ray before starting bleomycin treatment, and you may have regular chest x-rays during your treatment.
If you need an operation after having bleomycin, always tell the anaesthetist that you’ve had bleomycin treatment.
If sub-aqua diving is an activity you’re involved in, you may need to be careful about it after treatment with bleomycin, so talk to your doctor about this.
Changes to your hearing
Cisplatin can cause ringing in the ears (tinnitus) and might affect your ability to hear some high-pitched sounds. Tinnitus usually improves after treatment but changes to your hearing are often permanent.
Always let your doctor know if you have any changes to, or problems with, your hearing. They will monitor this closely and arrange hearing tests if necessary.
Numbness or tingling in the hands or feet
This is due to the effect of cisplatin on the nerves. It’s known as peripheral neuropathy. You may notice that you have difficulty fastening buttons or doing similar fiddly tasks.
Your hands and feet may also become more sensitive to the cold. It’s important to report your symptoms as they may be controlled by slightly lowering the dose of the drug.
This side effect usually improves slowly, a few months after the treatment has finished. Sometimes symptoms can persist – talk to your doctor if this happens.
Changes in the way your kidneys work
Chemotherapy (cisplatin in particular) can affect your kidneys, so you’ll have regular blood tests to check how well they’re working. You’ll also be given lots of fluid as a drip before and after having cisplatin.
Risk of blood clots
Cancer can increase your risk of developing a blood clot (thrombosis), and having chemotherapy may increase this risk further. A blood clot may cause symptoms such as pain, redness and swelling in a leg, or breathlessness and chest pain.
Blood clots can be very serious, so it’s important to tell your doctor straight away if you have any of these symptoms.
However, most clots can usually be successfully treated with drugs that thin the blood. Your doctor or nurse can give you more information.
It’s not advisable to father a child while taking any of the chemotherapy drugs used to treat testicular cancer, as the drugs may harm the developing baby. It’s important to use effective contraception (usually a ‘barrier method’, such as condoms) during your treatment and for at least a few months afterwards. You can discuss this with your doctor or nurse.
It’s not known whether chemotherapy drugs can be present in semen. To protect your partner, it’s safest to either avoid sex or use a barrier form of contraception for about 48 hours after chemotherapy treatment.
Chemotherapy for men with testicular cancer commonly causes infertility during treatment and for a time after.
This is usually temporary, but your doctor will advise that you consider storing sperm before having treatment. The rate at which the sperm count recovers varies from person to person, but it generally returns to normal from around 18 months or so after treatment.
In men having high-dose chemotherapy, the risk of infertility is much higher and infertility is often permanent.
Some men with testicular cancer have a low sperm count before they start treatment. Treatment with chemotherapy can sometimes improve sperm production.
High-dose chemotherapy with stem cell support
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High-dose chemotherapy with stem cell support allows you to have much higher doses of chemotherapy than usual to treat testicular cancer.
Before high-dose treatment, cells in your blood (called stem cells) are taken from you and stored. These stem cells help you produce new blood cells, which replace the ones that are damaged by the high-dose chemotherapy.
After the high-dose treatment, the stored stem cells will be given back to you through a drip into a vein (like a blood transfusion). They’ll go to your bone marrow and start to produce blood cells again.
This is an intensive treatment, and it means you’ll stay in hospital for several weeks. You’ll need a lot of nursing and medical care until you’ve recovered and your blood cells are improving.
We have a section on high-dose treatment with stem cell support. It explains more about this treatment and its possible side effects.