Testicular cancer: Which treatment should I have for stage I nonseminoma testicular cancer after my surgery?

Get the facts
Compare your options
What matters most to you?
Where are you leaning now?
What else do you need to make your decision?

1. Get the facts

Your options

For most men faced with testicular cancer, surgery to remove the testicle is the first treatment. After surgery, you must decide what to do next. For stage 1 nonseminoma testicular cancer, these are your choices:

Try watchful waiting. This means following a schedule of regular checkups and tests.
Have chemotherapy. It can kill any stray cancer cells.
Have surgery to remove the lymph nodes in your pelvis and lower back.

This decision aid is about stage I nonseminoma testicular cancer. For information about treatment options for stage I seminoma testicular cancer, see:

Testicular cancer: Which treatment should I have for stage I seminoma testicular cancer after my surgery?

Key points to remember

Lymph node surgery and chemotherapy are the surest ways to keep cancer from coming back.
Surgery and chemotherapy have risks and side effects. Watchful waiting lets you avoid these risks and side effects, or at least put them off for a while.
About 70 to 80 out of 100 men who choose watchful waiting are cured and don't have to worry about future treatment. This means that 20 to 30 of those 100 men do need treatment later.¹
For watchful waiting, you must be willing to have frequent checkups and tests. Without this close follow-up, if the cancer comes back it might not be found until it has spread and is harder to treat.
If you don't like the watchful waiting option but are worried that other treatment might harm your fertility, ask your doctor about banking your sperm before treatment.

FAQs

What is stage I nonseminoma testicular cancer?

There are two main types of testicular cancer: seminoma and nonseminoma germ-cell tumors. Seminomas can be treated with radiation. But radiation doesn't work well on nonseminomas. Also, nonseminoma cells are more likely to spread to the lungs, liver, and brain.

"Stage I" means that the cancer doesn't seem to have spread. Some stage I cancers actually have spread to the lymph nodes of the lower back but can't be seen.

Both types of cancer are very often cured, especially if they are found and treated early. Compared to other forms of cancer, testicular cancer—even when it has spread to other parts of the body—has a very high cure rate.

What are the treatment choices for stage I nonseminoma testicular cancer?

The first treatment is surgeryto remove the testicle. After that, most men have three choices: watchful waiting, chemotherapy, and lymph node surgery.

Watchful waiting

Watchful waiting means that you are being watched closely by your doctor but are not having further treatment.

You have exams, chest X-rays, and blood tests regularly during the first few years, as well as CT scans. It can be hard to go to the doctor's office that often. Unless your cancer comes back, the number of checkups and tests will gradually decrease over the next 10 years.²

With watchful waiting, you may be able to avoid the risks and side effects of lymph node surgery or chemotherapy. About 70 to 80 out of 100 men who choose watchful waiting are cured. They don't have to worry about future treatment. This means that about 20 to 30 of those 100 men do need treatment later.¹

Even when cancer is found after a period of watchful waiting, it is often easy to cure if it's found early. Because of this, many doctors consider it reasonable for some men to choose watchful waiting.

Chemotherapy

Chemotherapy, often called "chemo," is the use of very strong drugs to kill cancer cells. The most common chemo for nonseminoma testicular cancer is called cisplatin combination therapy. It uses several different medicines.

Chemo has a very high cure rate for this cancer. About 90 to 95 out of 100 men who have chemo are cured.³ This means that chemo doesn't cure the cancer in 5 to 10 out of 100 men.

Chemo is usually given at a low dose, so long-term side effects are rare.

Lymph node surgery

The full name for this surgery is retroperitoneal lymph node dissection, or RPLND for short. It is surgery to remove lymph nodes in the lower back and pelvis. These lymph nodes may contain cancer.

During the early phases of stage I nonseminoma testicular cancer, it can be very hard to tell if these lymph nodes have cancer without taking them out. In the past, doing this often caused infertility. Modern nerve-sparing and laparoscopic methods have greatly lowered the chances of infertility.

Lymph node surgery has a very high cure rate. Up to 90 out of 100 men who have the surgery are cured and don't need any more treatment.³ This means that surgery doesn't cure the cancer in 10 out of 100 men.

What are the risks of watchful waiting?

Perhaps the greatest risk of choosing watchful waiting has to do with missing your follow-up tests and exams. Without regular testing and checkups, you can miss cancer that has returned until it spreads beyond the lymph nodes and is harder to cure. If you choose watchful waiting, it's very important to strictly follow your doctor's schedule of tests and exams.

When cancer does come back during watchful waiting, it usually hasn't spread any farther than the lymph nodes in the lower back and pelvis. It can usually be treated successfully when the testing schedule has been followed closely.

What are the risks of chemotherapy?

Chemotherapy for testicular cancer has caused permanent infertility in some men. Because most men diagnosed with this cancer are younger than 35, this is important to think about when you choose which treatment to use.

Some men still need surgery after chemo to remove damaged tissue or remaining cancer. In those cases it is not always possible for the surgeon to use nerve-sparing methods that greatly reduce the chances of infertility.

Men who are going to have chemo should bank their sperm ahead of time if they want to father children in the future. Talk to your doctor about any fertility concerns you may have.

Side effects of chemo

Many men do not have problems with side effects from chemo. Other men have a great deal of trouble with them. If you have problems, your doctor can use other medicines to help you feel better.

Common short-term side effects include:

Nausea and vomiting.
Hair thinning or hair loss.
Mouth sores.
Diarrhea.
A higher chance of bleeding and infection.

The chemo used for testicular cancer has also been linked with serious long-term side effects. But these aren't common. These side effects may include:

High blood pressure.
Increased cholesterol levels.
Kidney, heart, and lung damage.
Increased risk of other cancers, such as leukemia and melanoma.³

What are the risks of lymph node surgery?

The risks and side effects of lymph node surgery for testicular cancer include:

Chylous ascites. With this condition, digestive fluids collect inside the belly. This may cause belly pain and make it hard to breathe.
Lymphedema. This is a collection of fluid that causes swelling in the arms and legs.
Bleeding.
Pulmonary embolism. This is a sudden blockage of blood flow in the lung.

Fertility problems after surgery

Men who get lymph node surgery can end up with nerve damage that causes retrograde ejaculation. This means that the semen flows up into the bladder instead of out through the penis. This makes you unable to father children.

In most cases, men with retrograde ejaculation don't have erection problems or trouble enjoying sex.

Laparoscopic and other nerve-sparing methods have greatly lowered the risk of retrograde ejaculation. Studies show that 95 out of 100 men who have nerve-sparing surgery have normal ejaculation afterward. That means that 5 out of 100 men do have retrograde ejaculation and are infertile after the surgery.²

Nerve-sparing surgery may be more difficult or impossible for men who have had chemotherapy. Talk to your doctor about whether nerve-sparing surgery is an option for you.

General surgery risks

Like any major surgery, the risks include:

Pain after surgery.Your doctor may give you a prescription for pain medicine or have you try over-the-counter pain medicine.
Reactions to anesthesia or medicines.
Infection.
Bleeding.

2. Compare your options

	Try watchful waiting	Have chemotherapy
What is usually involved?	You have frequent checkups, X-rays, blood tests, and CT scans during the first few years. You will need checkups and testing less often as the years go by and your cancer doesn't come back.	The chemotherapy drug is usually injected into a vein in your hand or arm. This method is called an IV. Treatment is most often done in a hospital. You have treatments for about 3 months.
What are the benefits?	Watchful waiting works for many men. Out of every 100 men who try watchful waiting, 70 to 80 remain free of cancer.³	Chemotherapy cures 90 to 95 out of 100 cases of stage I nonseminoma cancer.³
What are the risks and side effects?	It can be hard to follow the long and intense schedule of checkups and tests that are required with watchful waiting. Cancer may come back.	Side effects of chemotherapy can include nausea and vomiting, hair loss, mouth sores, and diarrhea. You may need surgery to remove damaged tissue or remaining cancer after chemotherapy. Chemotherapy can cause serious long-term health problems, including secondary cancers, but this isn't common. These cancers may not appear until many years after treatment. Chemotherapy causes infertility in some men.
	Have lymph node surgery
What is usually involved?	If you have open surgery, the doctor makes a long cut in your belly, from the breastbone to the pubic bone. If you have laparoscopic surgery, four smaller cuts are made instead. You are asleep during the operation. The hospital stay is usually 4 to 8 days for open surgery, and less if surgery is laparoscopic. Recovery from open surgery takes 6 to 12 weeks, and less if surgery is laparoscopic.
What are the benefits?	Surgery cures up to 90 out of 100 cases of stage I nonseminoma cancer.³
What are the risks and side effects?	Even with nerve-sparing techniques, 5 out of 100 men will become infertile after surgery.² Nerve-sparing surgery is not possible for some men. Like all major surgeries, lymph node surgery has risks, including infection, bleeding, and blood clots.

Personal stories

Are you interested in what others decided to do? Many people have faced this decision. These personal stories may help you decide.

For more information, see the topic Testicular Cancer.

Personal stories about choosing RPLND, chemotherapy, or watchful waiting for stage I nonseminoma

These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions.

" As a cyclist, I figured the swelling on my testicle was probably caused from over-training. But my wife made me go to the doctor to have it checked out. It's a good thing I did, because the doctor told me I had a stage I nonseminoma. Since we found it at an early stage and my prognosis was good, I was given the options of chemotherapy, RPLND surgery, or watchful waiting. At the time, I was spending a lot of time traveling to races so I decided that I didn't really have the time for all the checkups and tests that go with watchful waiting. And I wasn't comfortable with undergoing chemotherapy, so I chose RPLND. After the RPLND, I had some trouble with fluid retention in my legs and postoperative pain, both of which have since improved. I've been able to resume my cycling career. And my doctor says I'm cancer-free, so I have no regrets. "

— John, age 28

" After I got over the shock of my diagnosis, we talked about my treatment choices. My doctor told me that because we caught the cancer at an early stage, I had to decide on which treatment option was best for me. After discussing it with my wife, we decided on the RPLND. We also felt the stress of watchful waiting would be just too much for us, especially since we have a young child and would like to have another. While my doctor says that I'm still cancer-free after 2 years, the surgery did cause me to become infertile. Although I did bank sperm before the surgery, part of me wishes I had given more thought to watchful waiting. "

— Lorenzo, age 37

" When my doctor told me I had testicular cancer, I was devastated. I decided that I would do everything in my power to beat this disease. After discussing it with my doctor I decided to go ahead with chemotherapy. I knew there was a chance that I didn't need it, but I wanted to get it over with as soon as possible so I could continue with my life. Because my cancer was early-stage, the chemotherapy program wasn't very intensive. And the side effects were barely noticeable. That was a year ago and I feel great. I know I made the right decision for me. "

— Michael, age 31

" At first I couldn't believe what the doctor was telling me. How could I have cancer? I thought I was too young for something like that. After going through a period of denial and anger, I decided I was going to do whatever I could to beat it. My doctor said I was fortunate because we had caught it at an early stage. After orchiectomy, I was told I could either go for surgery to remove lymph nodes in my pelvis, have chemotherapy, or try watchful waiting. I decided to wait and see if my cancer was gone before having other treatment. I'm young and don't like the idea of having major surgery or chemotherapy if I don't have to, especially since they can cause other problems later on. The follow-up schedule has been hard to stick to at times. But it's been over a year and the doctor says I'm still cancer-free, so I think it's been worth it. "

— Sam, age 20

" After being diagnosed with a stage I nonseminoma, I decided to try a watchful waiting program after my orchiectomy. I made all of my follow-up appointments and felt confident that my cancer was gone for good. Well, about 8 months after I started the program, we found out that my cancer had spread to the lymph nodes in my pelvis. Now my doctor tells me that I'm going to need the surgery anyway and may also need chemotherapy to cure my cancer. "

— David, age 33

3. What matters most to you?

Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements.

I’m worried that if I have treatment, I may not be able to have children.

Not important

Somewhat important

Very important

I’m willing to put up with the possibility of not having children if it means that my cancer will be cured for good.

Not important

Somewhat important

Very important

A long schedule of regular checkups and tests during watchful waiting will be worth it if it means that I won’t need to have other treatment.

Not important

Somewhat important

Very important

I want to avoid chemotherapy.

Not important

Somewhat important

Very important

I want to avoid surgery.

Not important

Somewhat important

Very important

My other important reasons:

Not important

Somewhat important

Very important

4. Where are you leaning now?

Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now.

Watchful waiting

NOT using watchful waiting

Leaning toward

Undecided

Leaning toward

Chemotherapy

NOT having chemotherapy

Leaning toward

Undecided

Leaning toward

Surgery

NOT having surgery

Leaning toward

Undecided

Leaning toward

5. What else do you need to make your decision?

Check the facts

1. Does watchful waiting simply mean having a special test during your yearly checkup?

Yes
No
I'm not sure

You’re right. If you choose watchful waiting, you must be willing to follow an intense schedule of frequent checkups and tests.

2. Are surgery and chemotherapy the best choices for completely getting rid of the cancer?

Yes
No
I'm not sure

That’s right. Lymph node surgery and chemotherapy have very high cure rates.

3. If you’re worried that chemotherapy or surgery will leave you infertile, can you bank your sperm ahead of time?

Yes
No
I'm not sure

That’s right. If you’re worried that treatment may leave you infertile, you can bank your sperm ahead of time.

Decide what's next

1. Do you understand the options available to you?

2. Are you clear about which benefits and side effects matter most to you?

3. Do you have enough support and advice from others to make a choice?

Certainty

1. How sure do you feel right now about your decision?

Not sure at all

Somewhat sure

Very sure

2. Check what you need to do before you make this decision.

I'm ready to take action.
I want to discuss the options with others.
I want to learn more about my options.

3. Use the following space to list questions, concerns, and next steps.

References

Citations

National Comprehensive Cancer Network (2008). Testicular Cancer, version 2. Available online: http://www.nccn.org/professionals/physician_gls/PDF/testicular.pdf.
Vuky J, Motzer RJ (2003). Testicular germ cell cancer. In B Furie et al., eds., Clinical Hematology and Oncology, pp. 813–824. Philadelphia: Churchill Livingstone.
Raghavan D, et al. (2007). Bladder, renal, and testicular cancer. In DC Dale, DD Federman, eds., ACP Medicine, section 12, chap. 14. New York: WebMD.