Testicular cancer: symptoms, treatment and survival

Testicular cancer is a malignant tumour of the testicle, arising in most cases from germ cells (sperm-producing cells). It is the most common cancer in men aged 15–49 in the UK, with approximately 2,400 diagnoses per year. Despite its frequency in young men, it is one of the most curable cancers — around 50 men die annually, giving it an overall five-year survival rate exceeding 95%.

The most common symptom is a painless lump or swelling on or in one testicle — which may be noticed during self-examination or incidentally. Other symptoms include: a feeling of heaviness or discomfort in the scrotum; a dull ache in the lower abdomen, back or groin; a sudden collection of fluid in the scrotum (hydrocele); and changes in the size or shape of a testicle. In men with metastatic disease, symptoms may include back pain (retroperitoneal lymphadenopathy), breathlessness (lung metastasis) or gynaecomastia (breast enlargement — from beta-hCG production).

The NHS advises that men regularly examine their testicles — ideally once a month, after a warm bath or shower when the scrotal skin is relaxed. Support the scrotum in the palm of the hand and use the thumb and fingers to feel each testicle gently. Normal testicles are smooth, oval and firm; one is usually slightly larger and hangs lower. Look for any new lump, swelling, change in size or shape, or hardness. Any new change should be assessed by a GP promptly — the majority of lumps are benign, but all require assessment.

No. The majority of testicular lumps are benign. Common benign causes include: epididymal cysts (very common — smooth, fluid-filled lumps at the back of the testicle); varicocele (dilated veins in the scrotum, described as a 'bag of worms' feel); hydrocele (fluid collection around the testicle); epididymitis or orchitis (infection/inflammation — usually associated with pain and tenderness). However, any new lump must be assessed urgently by a GP, who will arrange scrotal ultrasound within 24 hours if malignancy cannot be excluded clinically.

The exact cause is not fully understood. The most important risk factor is cryptorchidism (undescended testis) — the testicle's failure to descend into the scrotum during fetal development, which increases testicular cancer risk 4–8-fold even after orchidopexy (surgical correction). Other risk factors include a personal or family history of testicular cancer, certain intersex conditions, infertility and European ethnicity. Testicular cancer is thought to originate from germ cell neoplasia in situ (GCNIS) — abnormal precursor cells present from birth that transform malignantly under the influence of puberty-related hormones.

The main types are germ cell tumours (95% of all testicular cancers): seminomas (~55% — slow-growing, radiosensitive, AFP always normal, peak incidence 30–45 years) and non-seminomatous germ cell tumours (NSGCTs, ~45% — including teratoma, embryonal carcinoma, yolk sac tumour and choriocarcinoma, peak incidence 20–35 years). Mixed tumours are classified and treated as NSGCTs. Rarer non-germ cell tumours include Leydig cell tumours (usually benign) and Sertoli cell tumours.

Three blood tumour markers are measured before orchidectomy and during follow-up: AFP (alpha-fetoprotein) — elevated in approximately 70% of NSGCTs; always normal in pure seminoma (any elevation means treating as NSGCT). Beta-hCG (beta human chorionic gonadotrophin) — elevated in approximately 20% of seminomas and many NSGCTs; very high levels are characteristic of choriocarcinoma. LDH (lactate dehydrogenase) — a general marker of tumour bulk used in the IGCCCG prognostic classification. Serial marker measurements after orchidectomy guide staging assessment and monitor treatment response.

Diagnosis begins with scrotal ultrasound, which is arranged urgently by the GP if a suspicious lump is found. If malignancy is suspected on ultrasound, tumour markers (AFP, beta-hCG, LDH) are measured. The definitive diagnostic and therapeutic procedure is radical inguinal orchidectomy — surgical removal of the entire affected testis through a groin incision. The specimen is examined histopathologically. CT staging of chest, abdomen and pelvis is performed after orchidectomy. Testicular biopsy (scrotal approach) should not be performed as it disrupts lymphatic drainage.

Radical inguinal orchidectomy is the primary surgical procedure for testicular cancer. The affected testis and spermatic cord are removed through a groin incision under general or spinal anaesthetic. The inguinal (groin) approach is used — not the scrotal route — to avoid disturbing the lymphatic drainage of the scrotum (which differs from that of the testis and retroperitoneum, and scrotal incision would change the lymphatic drainage pattern). The procedure takes approximately 30–60 minutes and is performed as a day case or with one overnight stay. Sperm banking is offered before the procedure where possible.

BEP (bleomycin, etoposide and cisplatin) is the standard platinum-based chemotherapy regimen for metastatic or relapsed testicular cancer. It is given in 21-day cycles — typically 3 cycles for good-prognosis disease, 4 cycles for intermediate or poor-prognosis. BEP is highly effective — approximately 80–90% of patients with good-prognosis metastatic testicular cancer are cured. Side effects include nausea, hair loss, fatigue, infection risk, bleomycin-related lung toxicity, cisplatin-related hearing loss and peripheral neuropathy, and effects on fertility.

Yes. Testicular cancer and its treatment can affect fertility. Orchidectomy removes one testicle; most men retain adequate testosterone and sperm production from the remaining testicle. However, chemotherapy — particularly cisplatin-based BEP — can temporarily or permanently reduce sperm count. Radiotherapy also affects fertility. The NHS mandates that sperm banking must be offered to all men before chemotherapy or radiotherapy for testicular cancer. Recovery of fertility after chemotherapy occurs in approximately 50% of men within two years.

Testicular cancer has excellent cure rates. Five-year survival: Stage I — approaching 100%; Stage II — approximately 95%; Stage III (metastatic good prognosis) — approximately 90%; poor-prognosis metastatic — approximately 50–70%. Overall five-year survival across all stages is approximately 96–98%. Testicular cancer is one of the few solid tumours where even metastatic disease can be cured — BEP chemotherapy achieves cure in the majority of patients with good-prognosis metastatic disease.

In most cases, yes. One testicle is sufficient to produce normal levels of testosterone — the remaining testicle typically compensates. Testosterone deficiency (hypogonadism) after orchidectomy for testicular cancer is uncommon but can occur, particularly if the remaining testicle has reduced function due to the underlying condition (infertility and altered spermatogenesis are common in men with testicular cancer even before treatment). If testosterone deficiency is confirmed by blood tests, testosterone replacement therapy is available and effective.

Relapse rates vary by stage and histology. Stage I seminoma on surveillance: approximately 15–20% relapse, though virtually all are cured with subsequent treatment. Stage I NSGCT on surveillance: approximately 25–30% relapse, most cured with BEP. After BEP for metastatic disease: relapse depends on the risk group — approximately 10–30%. Relapsed testicular GCT is treated with salvage BEP regimens or high-dose chemotherapy with autologous stem cell transplant. Even relapsed testicular cancer has cure rates substantially higher than most other solid tumours.

Orchidectomy does not affect sexual function or testosterone levels in most men. Libido, erection and orgasm are unaffected by removal of one testicle. Men may experience psychological concerns about body image, which is normal — support from the clinical nurse specialist, peer support groups (Orchid, Macmillan) and counselling are available. Testicular prostheses (implants) are offered to men who wish them, inserted at the time of orchidectomy or at a later date, to restore normal scrotal appearance.

Retroperitoneal lymph node dissection (RPLND) is a surgical procedure to remove lymph nodes in the retroperitoneum (the space behind the abdominal organs) — the primary lymphatic drainage site for the testes. It is used for selected patients with residual retroperitoneal masses after chemotherapy (particularly in NSGCTs, where residual masses may contain viable tumour or mature teratoma) and in some Stage II NSGCTs as primary treatment. It is a complex operation performed at specialist centres, with risk of ejaculatory dysfunction (retrograde ejaculation) from disruption of sympathetic nerve fibres.

In low-income countries, testicular cancer is less frequently diagnosed early due to limited access to scrotal ultrasound and tumour marker testing. BEP chemotherapy — the highly effective standard treatment — requires cisplatin, etoposide and bleomycin, which may be unavailable or unaffordable in many settings, and requires specialist oncology nursing and close monitoring for toxicity. The high cure rates achievable in high-income countries are not replicated where chemotherapy access is limited. World Aid Network funds cancer treatment through locally-licensed oncologists.