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Lance Armstrong Testicular Cancer

As Lance Armstrong crossed the finish line on the Champs Elysees in Paris to clinch a third consecutive victory at the 2001 Tour de France, the triumph was surpassed only by the defeat of a bigger competitor in the young athlete's life--testicular cancer.

In 1996, Amstrong began experiencing early warning signs of testicular cancer, but unfamiliar with the disease, the sportsman chalked up the symptoms as byproducts of his intense training regimen.

"Of course, I should have known that something was wrong with me. But athletes, especially cyclists, are in the business of denial," Armstrong writes in his bestseller, It's Not About the Bike. "Everything hurts. Your back hurts, your feet hurt, your hands hurt, your neck hurts, your legs hurt, and of course your butt hurts. So no, I didn't pay attention to the fact that I didn't feel well in 1996. When my right testicle became slightly swollen that winter, I told myself to live with it, because I assumed it was something I had done to myself on the bike, or that my system was compensating for some physiological male thing."

Six months later, Armstrong's symptoms worsened. Episodes of coughing up blood, brain-crushing headaches, blurred vision, and increasing testicular swelling finally prompted the 25-year-old to seek help from his physician. Within hours the champion's life changed forever.

After physical examination and x-rays, his physician delivered a stunning diagnosis--advanced testicular cancer--recommending surgery the following morning to remove his right testicle. Later consultations only confirmed the initial diagnosis in more alarming detail--the cancer, a rare and aggressive type called choriocarcinoma that is difficult to arrest, had spread to his lungs, abdomen, and brain. Follow-up tests revealed 40 tumors in his lungs and two in his brain.

"I was given less than a 40 percent chance of surviving," Lance wrote. "And frankly, some of my doctors were just being kind when they gave me those odds."

Armstrong became a student of testicular cancer, undertaking a crash course on the disease, reading books, articles, and scientific literature on the latest treatment strategies. One name that immediately surfaced was Dr. Larry Einhorn, who in 1974 pioneered the use of three chemotherapeutic agents that revolutionized the treatment of the disease and, in the process, saved thousands of lives. Discovering that the Indiana University Medical Center was the world's leader in treating testicular cancer, Armstrong phoned for an appointment and was scheduled for the following day. He then flew to Indiana to meet with Dr. Einhorn and his associate, Dr. Craig Nichols.

After surgery to remove the brain tumors and an intensive chemotherapy regimen, Armstrong's condition improved, as did his chances for survival. One year later, Armstrong attempted one of the most amazing comebacks in sports history, one few believed he could achieve.

Last October, Lance celebrated his five-year anniversary of surviving cancer. Now a passionate advocate for cancer research across the globe, the athlete is equally passionate about the men and women who helped him reenter the winner's circle and life, especially the team at the Indiana University School of Medicine.

To find out more about testicular cancer and the importance of early detection, the Post interviewed Dr. Lawrence Einhorn, distinguished professor of medicine at the Indiana University School of Medicine and former president of the American Society of Clinical Oncologists.

Q: Since the 1970s, the percentage of patients surviving testicular cancer has risen dramatically. What is the cure rate for testicular cancer today?

A: Thirty years ago, if you took every single patient with testicular cancer, about 50 percent of them survived their disease. Ninety percent of patients in whom the cancer had metastasized, or spread to distant parts of the body, died. Today, 95 percent of all patients with testicular cancer and 80 percent of patients with metastatic disease are cured.

Q: What an amazing reversal. How many cases of testicular cancer occur each year?

A: In the United States, there are 8,000 new cases annually.

Q: Has the incidence of the disease increased?

A: Yes. During the last couple of decades, the incidence has been steadily and clearly rising. Unlike prostate cancer, testicular cancer is still a rare disease; one man out of 400 gets testicular cancer in his lifetime.

Q: Do researchers know what is behind the increasing incidence?

A: No one knows why. Testicular cancer is among several cancers where the incidence is increasing and the reason why remains elusive.

Testicular cancer is a disease of young, healthy men who die rapidly if the disease goes undiagnosed. Left untreated, testicular cancer is not something that people live with for years and years.

Q: How are testicular cancers typically discovered?

A: Most of the time, the patient will experience symptoms such as a lump, mass, or fullness in one testicle compared to the other. Pain in the testicle, scrotal sac pain, or flank pain due to spread of the disease from the testes to lymph glands in the abdomen (causing back pain) are also symptoms of the disease.

Q: Champion cyclist Lance Armstrong has been very outspoken about testicular cancer. Have he and other athletes such as Scott Hamilton helped raise public awareness of the disease?

A: Absolutely. The situation is somewhat analogous to what occurred 30 years ago when Betty Ford and Happy Rockefeller went public about having breast cancer. Most men had never heard of testicular cancer. The fact that these well-known individuals have gone public and increased public awareness of this disease means that more men are going to be diagnosed at an earlier stage when less treatment is required, and the cure rate is almost universally 100 percent when caught early.

Q: When a lump is discovered on a testicle, does it always indicate testicular cancer, or can it indicate the presence of other conditions, such as epididymitis?

A: Most patients with an abnormality within the scrotum, or sac, will have a benign cause, such as epididymitis, rather than a malignant one. But you should not ignore any abnormality. If unsure of what you are feeling in the testicular area, you don't want to be your own doctor. Have a physician examine it to see if a problem exists. The physician will determine if an x-ray or a testicular ultrasound is necessary.

Q: During self-examination, what exactly are you looking for on the testicle, and where are lumps usually discovered?

A: Basically, when you feel a testicle, it is like feeling a clinched fist. The testicle will feel firm. As you run your fingertips along the surface of a clinched fist, you eventually hit the knuckle. You can feel a difference in consistency between the back of the hand or clinched fist versus feeling that knuckle behind the second, third or fourth finger. Basically, you are feeling to see if there is a nodule, lump, or bump inside the testicle itself.

Q: Besides a lump, what other symptoms accompany the disease?

A: Pain. But a person could have just a lump alone with no pain at all.

Q: So pain by itself is not necessarily a reliable symptom?

A: No. But if someone has testicular pain, you want to have a physician examine the testicle. If the testicle feels perfectly normal, there is no problem. But if something is there, it needs to be investigated further.

Q: Is testicular examination part of routine physical examinations?

A: It should be. But often it is not.

Q: Are other tests used to verify the diagnosis of testicular cancer?

A: If a physician suspects that something is going on in the testicle, testicular ultrasound is considered the gold standard for diagnosis. We would also order other blood tests, such as the human chorionic gonadotropin (HCG) and the alpha-fetoprotein (AFP), blood markers that help track the levels of various proteins that indicate how much cancer is in the body. These are not tests used to rule out the diagnosis of testicular cancer, because you can have testicular cancer and still have normal blood tests.

Q: In October, Lance Armstrong passed the five-year mark of being cancer-free. He noticed something was wrong six months before seeking medical attention. Did that delay cause problems?

A: Yes. When you delay responding to symptoms and arrive with more advanced disease, at best you require more aggressive and extensive therapy; at worst, you can die from the disease.

Q: Is his tremendous comeback unusual, or have treatments for testicular cancer progressed this far?

A: When Lance first sought medical attention with his advanced cancer, the extent of his disease was such that he basically was told he had a 50 percent chance of surviving the disease.

Q: Had Armstrong's cancer metastasized to his lungs?

A: Yes, as well as to the brain and abdominal lymph glands.

Q: What role did Armstrong's spirit and determination play in his recovery?

A: It's always nice to say that you can "wish" away a cancer. But I guarantee that every young man with testicular cancer has spirit and determination. Being a professional athlete, Lance was mentally and physically strong, which probably helped him successfully survive a very difficult period in his life. Lance's story, however, is no more or no less remarkable than what all our patients go through when they have testicular cancer and undergo chemotherapy.

Q: Is it unusual for an athlete of Armstrong's caliber to return to such a demanding sport after surviving life-threatening cancer?

A: Absolutely. His successful return is unusual not simply because he survived the cancer. When you look at professional athletes such as Michael Jordan, who retired and staged a comeback, it's very unusual--even in the best of health--that an athlete can return and compete at the same level as before. That is where Armstrong's spirit and determination did make a difference.

Q: Do certain sports, such as riding bicycles, or testicular injury increase a man's risk of testicular cancer?

A: Not at all. What does happen when you have testicular cancer--and this was true in Lance's case--is that he noticed a lump in the testicle. As an athlete, he assumed that the lump resulted from sitting on the bicycle all the time, which was part of the reason for his late diagnosis. Many people have a history of sports injury that brings attention to a mass already present. So in some cases, an injury in there is good because you will feel your testicle and say, "Oh, my God, there is a lump!" But again, there is no relationship to trauma of any kind in any type of cancer.

Q: What are the principal therapies used today to treat testicular cancer?

A: Treatment depends upon the extent of disease. If the disease is confined to the testicle and hasn't spread, or metastasized, to other parts of the body, the surgical removal of the testicle, or an inguinal orchectomy, is potentially the only measure necessary.

If the disease has spread to the abdominal lymph glands with relatively small metastases there, the lymph glands are at times treated with surgery or radiation therapy. On the other hand, if there is more extensive disease--and especially if it has spread to distant parts of the body like in Lance Armstrong's case--patients receive chemotherapy. Chemotherapy is, of course, a form of treatment that goes everywhere in the body (unlike surgery or radiation therapy, which are localized treatments).

Q: Is the chemotherapeutic medication cisplatin still regarded as the "magic bullet"for the disease?

A: For testicular cancer, it is.

Q: When is radiation therapy used?

A: Radiation is used in one particular type of testicular cancer, called seminoma.

Q: Is the disease usually located in one testicle, or does the cancer spread to both testicles?

A: The disease never spreads to the other side. But as with breast cancer, when you are cured of breast cancer, you can get a second cancer on the other side later on. About one percent of men with testicular cancer on one side will subsequently develop cancer on the opposite side.

Q: After one undergoes surgery to remove a testicle, do testosterone levels need to be checked, and is testosterone supplementation often required?

A: No. One testicle will work overtime, and testosterone levels will be perfectly normal.

Q: Could you tell us briefly about your discovery of the cure for testicular cancer and what is now called "the Einhorn Regimen"?

A: The discovery dates back a long time ago to 1974. Cisplatin was a drug being looked at for use in a variety of different cancers. Our group at Indiana was the first to combine it with other agents to develop a chemotherapy regimen that dramatically changed the cure rate in testicular cancer.

Q: Although testicular cancer is the most common cancer in young men between the ages of 15 and 35, can it strike men at later ages in life?

A: Absolutely.

Q: Is self-examination, then, a concern for men of all ages?

A: I don't know if I would use the word "concern." Testicular cancer is sort of the opposite of prostate cancer, where the older you are, the higher the probability is of getting the disease. In testicular cancer, the older you are, the lower the probability is of getting it.

Q: Many older men today are taking testosterone supplements as an antiaging therapy. Does testosterone supplementation raise the risk of testicular cancer?

A: Again, if you don't know what the cause is, it is impossible to know the answer. But there doesn't seem to be any plausible reason why taking testosterone would be harmful as far as testicular cancers go. That doesn't mean that testosterone supplementation is not harmful for other medical conditions, but certainly in terms of testicular cancer, it doesn't seem to be.

Q: Have improvements in this surgery resulted in improved ejaculatory function and less disruption of involved nerves?

A: Absolutely. In the past, the surgery was called a radical RPLND. Now it is referred to as a nerve-sparing RPLND. In that procedure, surgeons are able to remove the cancerous lymph nodes but at the same time not cut nerves that control the forward movement of sperm. In this way, patients are still able to ejaculate normally and do not experience a significant effect on the ability to father a child.

Q: Many men worry that the removal of the testicle and cancer treatments will affect their ability to perform sexually and father children. How do you address these fears?

A: Just by talking to the patient and with education. Sometimes physicians as well as patients confuse the term "impotence" with "infertility." There is no form of treatment for testicular cancer that affects your sexuality and ability to have a normal sexual relationship. What is affected with some of the treatments is the ability to father a child.

Q: What is the surveillance protocol after testicular cancer therapy?

A: Surveillance depends upon your stage of disease. If a patient is treated with removal of the testicle alone, the surveillance is more intensive. On the other hand, in someone like Lance Armstrong who has been through chemotherapy and is in complete remission, follow-up is less intensive.

Q: Could you tell us about your recent and hopeful new research into high-dose chemotherapy followed by stem-cell transplantation for testicular cancer patients who experience recurrence?

A: This therapy is for patients who are not cured by their initial chemotherapy, and the cancer progresses and returns after initial chemotherapy. Even in that unfortunate situation, with high-dose chemotherapy we are still able to cure about half of the patients the second time around.

Q: Do children born with an undescended testicle have an increased risk of testicular cancer?

A: Absolutely. That is the only known risk factor for testicular cancer.

Q: Are obesity, twin pregnancies, and other conditions that raise estrogen levels associated with higher risk of testicular cancer?

A: No. There is a questionable association for children born of mothers who took DES, or diethylstilbesterol, but even that is questionable.

Q: Are there any advances in molecular or blood markers to detect testicular cancer at an earlier stage?

A: Nothing recent. The blood tests that I mentioned--the HCG and the alpha-fetoprotein--have been around for 25 years, and those are extremely valuable blood tests. We wish we had equally valuable blood tests in all forms of cancer like we do in testicular cancer. They are sort of the quintessential tumor markers.

Q: What is the most important message about testicular cancer that you would like to share with our readers?

A: The most important thing--and what Lance Armstrong has been great about doing--is letting people know that the disease exists. Lance's message is that he does not want other people who notice a mass in their testicle for six months to wait and not remotely link that mass to a life-threatening disease like cancer. Certainly in Lance's case, if he had gone to a physician the first time he noticed a lump in the testicle, he almost certainly would have been able to avoid chemotherapy and not have to go through a very tough period of life. The main message is, there is such a thing as cancer of the testicle. Prior to Lance, very few young men even remotely thought that you could get cancer in that part of the body.

Q: Your contributions in the battle against testicular cancer mortality are now legendary. Why did you decide to tackle testicular cancer as you were beginning your career in medical oncology?

A: Actually, it is not quite that simple. Back then, I did research in all forms of cancer--still do. Testicular cancer has just been a unique success story. But I have always been and still am involved in many other forms of cancer research--lung, prostate, bladder, and other forms of malignancies.

The Facts:

[check] Although cancer of the testes accounts for only about one percent of all cancers in men, it is the number one cancer killer among men in their 20s and 30s.

[check] Testicular cancer develops more frequently in whites than in blacks or Asians.

[check] Men with a history of undescended testicles are at higher risk.

[check] With early detection and treatment, 90 percent of those affected are cured.

Remember that testicular cancer is highly curable, especially when treated promptly. Testicular cancer almost always occurs in only one testicle, and one testicle is all that is needed for sexual and reproductive function.

Testicular Self-Examination

Just as women perform routine breast self-examination, all males 15 and older should perform routine testicular exams. The National Cancer Institute recommends following these steps every month:

* Stand in front of a mirror. Check for any swelling on the scrotum skin.

* Examine each testicle with both hands. Place the index and middle fingers under the testicle with the thumbs placed on top. Roll the testicle gently between the thumbs and fingers. Don't be alarmed if one testicle seems slightly larger than the other. That's normal.

* Find the epididymis, the soft, tubelike structure behind the testicle that collects and carries sperm. If you are familiar with this structure, you won't mistake it for a suspicious lump. Cancerous rumps usually are found on the sides of the testicle but can also show up on the front.

* Other signs which should be reported include: enlargement of a testicle, a heavy feeling in a testicle, or an accumulation of fluid in the scrotum.

* If you find a lump, see a doctor right away. The abnormality may not be cancer, but if it is, the chances are great that it can spread if not stopped by treatment. Only a physician can make a positive diagnosis.

Letter from Lance Armstrong in tribute to Dr. Einhorn:

"It is with great enthusiasm and appreciation that I write to thank you and the Indiana Historical Society for honoring Dr. Larry Einhorn as an Indiana Living Legend. In my mind, however, he is more than an Indiana legend: he is an international Living Legend.

"Words cannot quantify the respect and admiration I have for Dr. Einhorn. His scientific accomplishments are equaled by few other physicians, and his passion for treating patients is apparent in everything he does.

"I owe unending thanks to Dr. Einhorn for saving my life. And while I have been blessed to continue my cycling career, my biggest blessing is the life I share with my wife, Kristin, our son, Luke, and our twins who are on the way.

"Please relay my sincere congratulations to Dr. Einhorn, and thank you for recognizing this amazing man."

Sincerely, Lance Armstrong

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