Beyond the Physical: Exploring the Psychological Journey of Testicular Cancer Survivors
Dhwani Patel, Ching Yung Yuan, Mackenzie Smith
April 2024
Testicular cancer is a prevalent and serious disease affecting the male reproductive system, specifically targeting the cells of the testicles and scrotum (1). Despite being the most prevalent solid tumour type in males, nearly two-thirds of men between the ages of 18-34 (assigned male at birth) do not know that they fall within the age group most at risk for testicular cancer, and do not know how to perform a self-examination (1). Testicular cancer can lead to many significant side effects in males, including pain and heaviness in the testicles, enlarged lymph nodes, weight loss and infertility issues (1).
Understanding the impact of a testicular cancer diagnosis
Along with the physical side effects, it is important to highlight the significant psychological effects associated with a testicular cancer diagnosis. A study revealed that 6.1% and 7.9% of long-term testicular cancer survivors reported experiencing anxiety and depression, respectively (2). This calls attention to the importance of understanding the mental health tolls experienced by men upon diagnosis with and living with testicular cancer (2). Emotional turmoil is common upon testicular cancer diagnosis, with many men expressing uncertainties and fears surrounding their disease (2). Such fears can include questioning their masculinity, worry of infertility, as well as fear of treatment options (2).
Psychological strain of surgery
The primary treatment that is recommended for testicular cancer patients is an orchidectomy, a surgical procedure to remove the affected testicle, often followed by a course of chemotherapy and radiation based on the cancer’s severity (2). There are several psychological tolls the patient experiences before, during, and after the treatments are given (2,3). These experiences are unique to the individual, their cancer type, stage, treatment severity, and their support system during the treatment process (2). Research shows that 25% of testicular cancer survivors have heightened anxiety post-diagnosis (2). Furthermore, research reveals concerns among survivors who underwent chemotherapy regarding their fertility and future as fathers. The anticipation of surgery, potential complications, and post-operative recovery also contribute significantly to emotional distress, with waiting for post-surgery scans eliciting strong feelings of fear and helplessness. (2,3).
There were mixed feelings about opting for a testicular prosthesis, an artificial replacement for the removed testicle (4). Individuals who wanted to get the prosthesis believed that it would help with feelings of loss of masculinity, self-image, and overall confidence in their bodies (5). Individuals who opted against the prosthesis reasoned that they were comfortable living with one testicle and did not believe it to have a significant impact on their self-image (5). However, they also admitted to having no desire to undergo another surgery, as it felt invasive, and showed concerns about the safety of the surgery (5).
Psychological impacts of treatment side effects, body image issues, and fertility
Testicular cancer mainly affects males between the ages of 15 and 45 years old (2). Individuals who receive their diagnosis during their prime developmental years as teenagers and young adults are more likely to have poor mental health and a negative self-image perception (2). This critical phase coincides with crucial life milestones such as building relationships, pursuing career aspirations, and envisioning the future, all of which can be profoundly impacted by a testicular cancer diagnosis, leading to feelings of uncertainty and demoralization (2).
The side effects of testicular cancer treatments can have a significant toll on the patient’s psychological state. This includes reduced sexual desire, orgasm ejaculation, and sexual activity (3). Survivors who are already in a relationship often engage in reflective conversations about the impact of cancer on the relationship, addressing lifestyle changes, future career plans, coping with emotional and physical side effects due to treatment, and the fear of disease recurrence (2). Generally, individuals who already had partners at the time of diagnosis and throughout the treatment process displayed better adaptation to the cancer and during the survivorship phase (2).
Individuals who were not in a relationship admitted to worrying about their fertility, sexual performance, and future health regarding future relationships (2). Feelings of embarrassment regarding their cancer and the negative perception of their body often raised doubts about disclosing their cancer history to partners (2). Additionally, some individuals expressed regret that they wish they had inquired about fertility preservation treatments before undergoing orchidectomy (5).
One of the biggest emotional consequences of orchidectomy is the loss of masculinity (6). More than half of the respondents to the follow-up surveys reported needing additional support with the adjustment to their new bodies and with feeling masculine again (6). Frustration was also common as individuals did not feel “strong enough” for their partner (6). The prevalent mental health issues, including anxiety and depression, underscore the importance of comprehensive psychological support throughout the testicular cancer treatment journey (6).
Long-term mental health impacts and coping strategies
Testicular cancer is highly treatable at a cure rate of 95%. Patients who undergo treatment (usually chemotherapy or radiation therapy) in their 20s have the prospect of many healthy years ahead (7). However, the journey doesn’t end with successful treatment; many patients grapple with lasting physiological and psychological effects. A study that surveyed 1,200+ cancer survivors who had chemotherapy found that the majority of patients (76%) suffered from a medium burden of side effects whereas a striking 19% of patients suffered from significant impacts (7). These long-term impacts on patient health may involve anything from chemo-induced lung and kidney issues to neurological decline, loss of fertility, and psychosocial issues requiring therapy and other forms of rehabilitation (8).
Common chemotherapeutic agents such as Bleomycin and Cisplatin, while effective against cancer cells, can deposit in various tissues, leading to off-target effects. Bleomycin has been associated with lung inflammation, eventually leading to lung tissue scarring (7). For patients with a highly active lifestyle before treatment with Bleomycin, this change in lung tissue can cause significant changes to their lifestyle. Conversely, Cisplatin has been linked to heart disease, hearing loss, and loss of sensation in peripheral nerves (8). During the later stages of life, the cardiovascular impact of chemotherapy becomes one of the most important causes of premature death among testicular cancer survivors (8). Although alternative treatments like carboplatin exist, they may not provide the same therapeutic benefit.
Furthermore, surgical removal and therapy-induced damage to cells responsible for testosterone synthesis leads to long-term hormone imbalances. Low testosterone among testicular cancer survivors contributes to decreased sex drive, erectile dysfunction, chronic fatigue, hot flashes, mood changes and depression, muscle and bone loss, and metabolic syndrome (9). Metabolic syndrome refers to a group of conditions (obesity, high blood cholesterol, high blood pressure) which are closely linked to ailments such as stroke, diabetes, and heart disease (9).
A lot of the psychological changes following testicular cancer have to do with hormone imbalances, overall physical health, and mood. However, yet another significant contributor to the alteration in mental health comes from the patient’s changing self-perception regarding their diminished masculinity (10). Single, childless patients often struggle more due to lacking relational support and feeling disconnected from societal expectations tied to masculinity (10). In addition, men who associate the loss of their testicles more heavily with a loss in masculinity had a harder time rebounding from the aftermath of therapy (10).
Much of the long-term effects of therapy can be managed with regular screening and treatment, especially for hypertension and heart disease. There has been an established link between obesity before the testicular cancer diagnosis and the appearance of late effects (11). Patients in this category are especially encouraged to have regular health checkups (11). Another lifestyle factor that may compound the effect of cancer therapy is smoking, which may add more lung injury on top of the fibrosis already evident following bleomycin treatment (11). In addition, there has been some evidence of exercise as a good way to boost testosterone levels (12). Overall, regular screening and a healthy lifestyle will do wonders for survivors of testicular cancer (12). Psychiatric care is also a crucial piece of the patient’s long-term, holistic health that will lead to a long healthy life following cancer.
References
1. Canada M. Almost two thirds of Canadian men aged 18-34 don’t know their testicular cancer risk. https://www.newswire.ca/news-releases/almost-two-thirds-of-canadian-men-aged-18-34-don-t-know-their-testicular-cancer-risk-885690275.html.
2. Schepisi G, De Padova S, De Lisi D, Casadei C, Meggiolaro E, Ruffilli F, et al. Psychosocial Issues in Long-Term Survivors of Testicular Cancer. Frontiers in Endocrinology. 2019;10: 113. https://doi.org/10.3389/fendo.2019.00113.
3. Patient-Reported Outcomes Associated with Treatments for Testicular Cancer: A Systematic Review. https://doi.org/10.2147/PROM.S242754.
4. Carpentier MY, Fortenberry JD. Romantic and Sexual Relationships, Body Image, and Fertility in Adolescent and Young Adult Testicular Cancer Survivors: A Review of the Literature. Journal of Adolescent Health. 2010;47(2): 115–125. https://doi.org/10.1016/j.jadohealth.2010.04.005.
5. Testicular prosthetics: what you need to know. https://nutsandbolts.movember.com/resources/testicular-prosthetics-what-you-need-to-know/.
6. Alexis O, Adeleye AO, Worsley AJ. Men’s experiences of surviving testicular cancer: an integrated literature review. Journal of Cancer Survivorship. 2020;14(3): 284–293. https://doi.org/10.1007/s11764-019-00841-2.
7. Moul JW, Robertson JE, George SL, Paulson DF, Walther PJ. Complications of Therapy for Testicular Cancer. Journal of Urology. 1989;142(6): 1491–1496. https://doi.org/10.1016/S0022-5347(17)39135-8.
8. Kerns SL, Fung C, Williams A, Abu Zaid MI, Sesso HD, Monahan P, et al. Cumulative burden of morbidity (CBM) among testicular cancer survivors (TCS) in the Platinum study. Journal of Clinical Oncology. 2016;34(15_suppl): 10089–10089. https://doi.org/10.1200/JCO.2016.34.15_suppl.10089.
9. Walsh JS, Marshall H, Smith IL, Greenfield DM, Swain J, Best E, et al. Testosterone replacement in young male cancer survivors: A 6-month double-blind randomised placebo-controlled trial. PLoS Medicine. 2019;16(11): e1002960–e1002960. https://doi.org/10.1371/journal.pmed.1002960.
10. Dax V, Ftanou M, Tran B, Lewin J, Wallace R, Seidler Z, et al. The impact of testicular cancer and its treatment on masculinity: A systematic review. Psycho‐Oncology. 2022;31(9): 1459–1473. https://doi.org/10.1002/pon.5994.
11. Hashibe M, Abdelaziz S, Al-Temimi M, Fraser A, Boucher KM, Smith K, et al. Long-term health effects among testicular cancer survivors. Journal of Cancer Survivorship. 2016;10(6): 1051–1057. https://doi.org/10.1007/s11764-016-0548-1.
12. Riachy R, McKinney K, Tuvdendorj DR. Various Factors May Modulate the Effect of Exercise on Testosterone Levels in Men. Journal of Functional Morphology and Kinesiology. 2020;5(4): 81. https://doi.org/10.3390/jfmk5040081.
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