Wouldn't it be nice if we could think of our cancer as a one time experience? Once you were through, you could at least say that you had been there, done that, and did not need to do it again. Unfortunately, life does not work that way. After surviving testicular cancer (or just about ANY cancer), it is safe to say that your odds of getting cancer again in your lifetime are higher than someone who never had cancer.

How high? That is hard to measure or predict. It is reasonably well known that a man who has had testicular cancer has a 2-3% chance of getting testicular cancer again in the remaining testicle. Other factors, such as type of treatment, family history, and environment also increase the risk that a survivor gets a completely new and different cancer later in life.

An article in the October 1997 issue of the Journal of the National Cancer Institute by Travis et. al. reported that there is a small but real increase in the incidence of secondary cancers in patients treated for testicular cancer. Travis et. al. published another article in September 2005 on the same subject in the same journal that provides even more data on the subject.

What does this mean? That is hard to say. However:

• It does not mean that a diagnosis of testicular cancer, in and of itself, implies that your risk of getting cancer again (other than another testicular cancer) is any different than the rest of the population. The study only followed men who had been treated with radiation and/or chemotherapy.

• It does not mean that men treated with chemotherapy or radiation in the past 10 years are subject to the same increased risk as the majority of men in the JNCI report. Today's chemotherapy and radiation protocols are far less toxic than those used in the mid 1980's and before.

• It definitely does not mean that you should avoid necessary treatment now because you are afraid of the potential consequences down the road.

• While these studies did not include surveillance or RPLND only patients, it seems reasonable to conclude that these patients would likely not suffer from the same sort of long term side effects as those treated with radiation or chemotherapy.

In the October 1997 issue of the JNCI, an editorial by Drs Nichols and Loehrer of Indiana University discussed the issues raised by Travis's study. They noted that the article had a variety of shortcomings and largely reflects the effects of treatments from a bygone era. Nonetheless, they noted that this report should cause all physicians and patients to pause and consider all the treatment strategies in germ cell tumors. I realize that these articles have grown old, but the lesson remains the same. Do what you can to cure the cancer, but don't overdo it. These treatments do cause side effects, some of which may affect your quality of life for the rest of your life or may even shorten your life. Try to use the minimum amount of treatment needed to cure the cancer. What is the minimum needed? That is the tricky part, but at least with testicular cancer you usually have the luxury of a good safety net if the treatment you choose is not enough. Excerpts from the editorial highlight these points.

"In some regards, the report of Travis & colleagues on second malignancies in long term survivors of testicular cancer is tantamount to unearthing a time capsule or encountering the forward ripple from a stone dropped in a pond long ago. This report is generally consistent with other reports from large, long term cancer registries. In aggregate, these works demonstrate an indisputable increase in second solid tumors and leukemias in patients receiving treatment for germ cell cancer. How to respond? Should these datas be greeted with a shrug and a 'so what?' or should this engender active tinkering with a very successful therapeutic program?"

"There is reason to hope that the results reported by Travis & colleagues represent a 'high tide' for the incidence of second solid tumors. Again, insufficient detail of treatment limits this speculation, but one can impute a lower incidence with modern therapy by remembering common treatment practices in this era that are now just falling out of common practice. Certainly, in the 60's, 70's and 80's, classic alkylators such as cyclophosphamide were used very commonly in germ cell tumor regimens. The duration of chemotherapy often extended to two years (even in the adjuvant setting) compared to the nine to twelve weeks of treatment now used. Radiation therapy has been largely eliminated in patients with non-seminomatous testicular tumors. Ports and doses have been limited in patients with seminoma including elimination of prophylactic mediastinal radiation therapy. More early stage patients with both seminoma and non-seminoma are being managed with surveillance which avoids active treatment in 70-85% of patients in this most common presentation."

"So, with these imperfect data demonstrating a low incidence of second malignancies, should we rethink our approach to therapy of germ cell tumors? Absolutely! The recognition that any treatment, even two cycles of chemotherapy or low dose radiation therapy, is likely to be associated with a definable risk of second malignancies should cause careful consideration of the relative benefits of such therapy. Such consideration should call into question such practices as primary chemotherapy for stage I disease (50-70% of patients receiving unnecessary chemotherapy), automatic chemotherapy for pathological stage II non-seminoma (50-70% of patients receiving unnecessary chemotherapy [after RPLND]),and additional radiation therapy to persistent masses in seminoma (0-5% benefit). Approaches that diminish the possibility of requiring chemotherapy or radiation therapy should be considered such as retroperitoneal lymphadenectomy in early stage non-seminoma and surveillance in early stage seminoma."

"The study of Travis & Colleagues is sobering and important. It should provide the impetus and mandate for long term follow up tied to detailed accounting of treatments received for testicular cancer. All cancer therapies can perturb the quality and quantity of survivorship. The tremendous success of therapy in testicular cancer should not dim the recognition of the second malignancies engendered by treatment or diminished responsibility for careful reporting of both short and long term treatment results."

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