What is it and Why does it work?

Radiation therapy is most commonly performed with x rays or electrons, which can be generated by a machine called a linear accelerator or by a radioactive isotope that is placed in the body surgically. In the case of testicular cancer, external beam radiation is always used.

Xrays and electrons are forms of ionizing radiation. In other words, they deposit energy and remove electrons from atoms and molecules. This creates highly reactive chemical species, like OH radicals and H3O+, and leads to physical damage of big molecules, especially DNA. That's the physics in a nutshell.

Biologically, the damage causes a stress response in the cells of the irradiated tissue. Normal cells have an enormous capacity to repair damage from radiation and chemical injury. Many forms of cancer, especially seminoma, have relatively poor repair capacity. We take advantage of this by giving treatments as several daily "fractions" from multiple directions. After each fraction, normal tissue has time to recover before the next treatment, while the cancer retains the damage. Undamaged cancer cells continue to grow and repopulate the tumour, so the treatment is administered over several weeks to beat back the persistent cancer cells.

Basically this is "carpet bombing" to catch any hidden seminoma cells lurking in lymph nodes. It works because your normal healthy cells have a much greater capacity to put up with the radiation damage and recover when the treatment ends. The downer is that patients on treatment often experience diarrhea, nausea and a loss of energy among other things. There might be room to reduce the side effects, but the current wisdom is that the treatment is highly effective and has relatively moderate side effects compared to other treatments we give. As such, seminoma patients are in a really special position. I think clinicians are cautious about trying to fix a good thing, though research into reducing the area radiated or using reduced amounts of chemotherapy is ongoing.

The typical treatment for Stage I Seminoma in the US is 2500 rads over a period of 15 to 20 days. In the UK, it is more common for the same total dose to be given over a period of 10 days. Everything is the same for Stage II Seminoma, except that an additional 1000 rads is given afterwards and is specifically aimed at the enlarged lymph nodes thought to be cancerous.

Seminoma treatments are given with two beams of x-rays. One beam is directed from the front, and the other from the back. The technique is often called "parallel opposed", or "AP-PA" which essentially means a beam directed front to back, followed by a beam directed back to front. The area to be radiated is typically the para-aortic region between the kidneys along with the inguinal or pelvic nodes on the same side as the testicular tumor. This approach is called the "hockey stick" or "dog leg" because of its shape. Many doctors now believe that radiating the inguinal nodes is not necessary, but the field is reasonably divided on the subject.

What are the side effects?

The body must work very hard during radiation therapy to repair the tissues injured by the treatment. Patients may feel unusually tired, and they should try and rest as much as possible. Many guys opt to continue working during their treatments. This is usually not a problem, but it often works out better if you can arrange to have the treatments in the late afternoon. Morning treatments can leave you fatigued for much of the day.

Other unpleasant effects of radiation therapy may include diarrhea, nausea, and vomiting. These problems can usually be controlled with medication. Also, there may be skin reactions in the area being treated, and it is important to treat the skin gently. Lotions and creams should not be used on these areas without doctor's advice.

Radiation therapy does not change the ability to have sex. Radiation therapy does, however, interfere with sperm production. Usually the effect is temporary, and most patients regain their fertility within a matter of months.

How does it feel?

The best way to learn how it feels is to read what others have experienced. The TCRC has many personal accounts of radiation treatments on the personal stories pages. To get you started, here is Steve's story:

I first became aware that there was such a thing as testicular cancer when I learned that an old high-school buddy died from it. After that I found out how to examine myself and what to look for. His death may have saved my life because ten years later, at age 32, I found something wrong with myself.

In October 1996 I first noticed a small lump in my left testicle. It took me a few days to be sure that there was really something wrong and to call a doctor. I saw my family physician and he couldn't even find the lump until I showed him exactly where it was. He referred me to an urologist who could barely feel the lump himself.

The urologist sent me off for an ultrasound exam. The girl who did the ultrasound exam had the radiologist come in and he repeated the exam, but would not tell me anything. I had to call the urologist's office to get his report. My fear was confirmed when the urologist's office wouldn't tell me anything, but wanted me to come back for another office visit to see the doctor again.

He told me that there was a 95% chance that it was cancer, he would have to biopsy, and I would probably lose the testicle. The next few days were spent preparing for surgery with blood tests, x-rays, paperwork, and research into what was happening to me.

A few days later, the worst was over. The orchiectomy went well, the tumor was one of the smallest the urologist had ever seen. After recovering from surgery and spending a few sleepy hours in my room, I had a series of CT scans. The next morning I was on my way home.

A few more days later I went back to the urologist for the pathology report. The pathology on my left testicle showed a Stage I Seminoma which had not spread outside the testicle itself to any surrounding structures. The blood tests which my urologist ordered to look for tumor markers in my blood were negative. The CT scans which were done the night after my surgery also showed no visible spread. My urologist referred me to an oncologist who referred me to the radiation oncologist for treatment.

The rad. onc. told me that based on the results of the pathology and other tests, the probability that I was cured was 85% with no further treatment. If I took the radiation the probability of cure could be raised to virtually 100%.

Radiation therapy damages the ability of all affected cells to regenerate themselves and reproduce. The normal healthy cells are more able to recover from radiation damage than the cancerous cells. Radiation treatments are given daily except for weekends and holidays. The weekend breaks give the body some time to recover a little.

He told me the acute side effects of my radiation therapy could be general fatigue, nausea, diarrhea, hair loss in the targeted areas, skin irritation (mild sunburn or itch). The nausea and diarrhea can be treated with an anti-emetic prescription. Loss of sexual desire may result from the fatigue, but sexual function is not impaired. Fertility is not normally impaired by the radiation, although my wife and I were advised to wait 6-12 months after treatments before attempting to conceive. (The sperm cells that are in the body at the time of radiation treatments may be damaged.) Because sperm production is a continuous process, I need to wait for a few production cycles to ensure that only healthy sperm remain. I was advised to try to eat well and increase my calorie and protein intake to help my body heal itself from the radiation.

After I consented to the radiation therapy, I was scheduled for a simulation session. During this session, I had to change into one of those ridiculous hospital gowns and lie on a table with the gown pulled up to my chest. Then they put my right testicle in a clamshell shield. The shield is a heavy, hollow metal sphere cut in two halves with a rectangular hole for the testicle to fit through. The sphere sits in a sort of ring stand. Then they put a blanket over my legs and genitals, exposing only the pelvis and abdomen. They took a couple of x-rays to locate the areas they would target for radiation. I was marked with a purple ink to identify the target areas and so they could align my body in future sessions with wall-mounted laser cross beams. They took several x-rays during the simulation session to adjust and fine-tune the areas they would treat. After that, the clamshell was removed and I went to another room for more CT scans. The whole simulation session took about an hour and a half. They scheduled my first treatment for two days later.

I received treatment in two areas. The pelvic area covered the left side of the groin from the base of the penis to about an inch below the navel. The abdominal area was a rectangle about 4 inches wide from the navel to the sternum. I received a total dose of 3000 rad over twenty daily treatments. The rad. onc. told me that this is about half of what many patients receive for various other cancers.

The treatments could be scheduled at my convenience, so I scheduled mine after work on the way home. Each treatment session took about 15 minutes. I changed into a gown and laid on the table. The rad. tech would put the clamshell on me and make sure I was lined up with the lasers that cross the room. Then they would all leave the room and I was radiated in the abdomen for about 15 seconds. They would come back in and rotate the machine so that it radiated up from below the table. They would leave and I was radiated for about 15 seconds. They would come back in, rotate the machine back to its normal position, insert the shield block in front of the x-ray window, and align me to treat the pelvis. They made a special shield block for me based on my x-ray pictures taken during the simulation. The block reduced the exposure to 1% of the full strength in the areas they wished to avoid such as the bladder and genitals. The pelvis was radiated about 60 seconds. With the shield block and clamshell in place, they estimated that my testicle would receive a total dose of about 3-5 rad after all the treatments.

The treatments affect everybody differently. I started to feel nauseous about two hours after the treatment and it lasted for two-four hours. The rad. onc. gave me a prescription for prochlorperazine for nausea which I would take one hour before treatments. After a few treatments I really needed it. I also got very tired and needed to lie down and rest for a couple of hours after treatments. I needed 9-11 hours of sleep each night during my treatments.

My treatments ended a few days before Christmas. After a few days the fatigue went away and I started to feel good again. By New Years Day I felt better than ever. I thank the Lord I'm done with treatments and have such a good prognosis. I'd like to put all this behind me and forget it, but I still have years of follow-up checks and bills to pay, so I won't ever be able to forget. Besides that, I need to warn others. Most people I've talked to have never heard that TC exists unless someone they know had it.

2004 Update:

I finished writing the above story in January 1997 after all the radiation treatment sessions were finished. What a relief it was to finally have it all behind me.

I went back to my urologist for followup visits each six months for the first two years, then annually after that. Each time he ordered a blood test, chest x-ray, and CT scan. The blood test was for tumor markers alpha-fetoprotein and beta-HCG. The beta-HCG test sometimes made the less-experienced blood-letters wonder why I was having a pregnancy test. And, of course, the x-ray and CT scans were looking for any tumors that may have spread from the primary tumor. Each time, I got a clean bill of health. My urologist told me after two years cancer-free, he considered me cured. I've been cancer-free for almost eight years now! [Editor's Note: Most seminoma recurrences happen within the first five years after treatment, but we recommend that you not "consider yourself cured" for at least ten years after treatment.]

I've probably answered a few hundred emails from men (and the people that care about them) who are facing TC and radiation over the past five years. I consider it a privilege to share the encouraging news of my recovery and answer questions about my experience. One thing I hear from folks again and again is that their experience was just like mine.