It's A Man Thing...

When Julian Cousins was told that the cancer that had cost him one testicle at the age of 24 had recurred in the other 13 years later, he saw the future as a stark choice between castration and death.
"The hospital wanted to book me in for the following Monday, but, at 37, I was not prepared to be a human being with no gender identity," says the south London tennis coach. "They told me I could have prosthetic testicles and wear patches to replace my testosterone, but that wasn't an acceptable solution for me. My view was, 'If that's all you can offer, I would rather die on my terms than live on yours'."
Four years later, Mr Cousins is alive on his own terms. In what turned out to be an inspired decision, he sought out Tim Oliver, professor of oncology at Barts and the London Hospital medical school, who had treated his first bout of cancer.
Prof Oliver has pioneered alternatives to orchidectomy - removal of the testicle - for patients who have already had one operation. He believes that, in time, we may see the same kind of revolution in the treatment of testicular cancer that has been seen in breast cancer care. Wherever possible, women are now offered a lumpectomy rather than a mastectomy. In future, lumpectomy may be available to men with small tumours, who today would lose a testicle.
After two courses of powerful chemotherapy, which "felt like being plugged into the National Grid" and left him feeling shattered, Mr Cousins's tumour had disappeared without the need for surgery. Next March, he is getting married. "Children are very important to my fiancée, and our relationship would have been extremely difficult - if not impossible - had I been unable to have a family," he says.
Each year, about 2,000 people are given a diagnosis of testicular cancer; those aged 18 to 32 are most at risk. For reasons that are not understood, the incidence of the disease has risen by 84 per cent in the past 25 years, and is still increasing. The good news is that the vast majority of those diagnosed can be cured. Because more men now carry out self-examination, doctors are seeing tumours earlier, when they are smaller and less likely to have spread. Survival rates for men whose cancer is confined to the testicle are now 99 per cent. Where the disease has spread, survival rates have leapt from five per cent in the Sixties to more than 90 per cent today - thanks, mainly, to highly effective chemotherapy.
Treatment for cancer of one testicle almost always involves its removal, sometimes accompanied by chemotherapy or radiotherapy; potency and fertility are normally unaffected. An unlucky two to three per cent of these patients will have cancer in both testicles, some simultaneously, and others years apart.
For them, castration used to be the only option - followed by hormone replacement therapy to supply testosterone, without which patients suffer hot flushes, are unable to have an erection and are at risk of osteoporosis. Castrated men cannot, of course, father children naturally and usually bank their sperm before treatment.
Prof Oliver has long been determined to find a less radical solution, particularly for young men who have their lives ahead of them and have not had any children.
"Surgeons operating on women with breast cancer used to remove part of the chest wall, the lymph glands and the whole breast - until research showed that this was no more effective than just removing the cancerous lump," says Prof Oliver. "Now that chemotherapy is so successful in curing testicular cancer, why should we waste all these testicles?"
For the past 10 years, he has offered men with small cancers of the second testicle the opportunity to have chemotherapy followed by a lumpectomy, where necessary. The advantages of such an approach are obvious, but according to the Orchid Cancer Appeal - a charity that Prof Oliver helped to found, and which helps to fund his research in this field - 99 per cent of men in Britain who could benefit are not offered the opportunity and end up being castrated.
"The risk with the less invasive treatment is that you turn out to be wrong and the cancer returns," says Prof Oliver, who believes that fear of recurrence prevents more oncologists from recommending this option. "Of the 28 patients we have treated, about 18 per cent have developed another tumour. But we have operated on those men at that point and they have all been fine."
Chris Demetriades, a civil servant from Essex, decided to take the risk when he developed cancer in his second testicle, 12 years after losing his first. "Being diagnosed with another lump sent me to the ends of the earth. I was 36, I hadn't had kids and my life was over.
"I made my choice not just because I wanted to have children naturally - I wanted to lead a normal life without pills and injections. Every man has his pride." Chris had two courses of chemotherapy, one of which made him very ill, and a lumpectomy.
He is now married with a two-year-old son, Aaron Oliver (named after the doctor who helped make his birth possible). "I know that there is a 30 per cent chance the cancer will recur and I do worry about that. I would like the chance to see my son grow up but, whatever happens, I have no regrets about my decision."
Few disagree that this approach should be offered routinely to men who have already lost one testicle. The next step is to offer it to young men with both testicles who have small tumours. "The fact that 23 per cent of tumours are now smaller than 2 cm raises the possibility of carrying out testis-preserving surgery, rather than orchidectomies, in young patients who have an excellent prognosis, and for whom long-term psychological and fertility issues assume greater importance," says Prof Oliver. "We need a randomised controlled trial to evaluate these issues."
"This option would apply only to men with very small tumours," says Prof Alan Horwich, head of the testicular tumour unit at the Royal Marsden Hospital in London, who supports the idea of a partial orchidectomy, if appropriate, for patients with only one testicle. "Where the cancer is in different sites in the testis, there is a chance that you may not remove it properly. Or you may remove the cancer, but leave pre-cancerous cells which would be likely to cause a new tumour later."
Prof Horwich believes that the emphasis in treating primary testicular cancer should focus on ensuring that no pre-cancerous changes have taken place in the remaining testicle, and on treating them early when they have, usually with low dose radiotherapy.
from Health Telegraph