Treatments for non-seminoma

The following are treatment options for the different stages of non-seminoma testicular cancer. The treatments you are offered will depend on the stage and the prognosis group. If the cancer comes back (recurs), the treatments offered will depend on the treatments that were used for the original cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Surgery is the first treatment for stage 1 non-seminoma. The testicle and spermatic cord are removed through a small opening in the groin. This is called a radical inguinal orchiectomy, or it can also simply be called an orchiectomy. It’s usually done as part of the diagnosis. The diagnosis will help determine your risk of the cancer coming back and will help your doctor decide whether more treatment is necessary. Some factors that increase risk of recurrence include:

• if cancer cells have entered blood or lymph vessels (called lymphovascular invasion)

• if cancer cells have spread to the spermatic cord

• if cancer cells have spread to the scrotum

If your doctor thinks the risk of recurrence is high, you may also be offered a retroperitoneal lymph node dissection (RPLND) to remove the lymph nodes from the back of the abdomen (the retroperitoneum).

Active surveillance is the preferred treatment after surgery for stage 1 non-seminoma. It involves regular and frequent follow-up to look for signs and symptoms that the cancer has come back. Tests done during follow-up visits include a physical exam, blood tests to check tumour marker levels and imaging tests (such as a chest x-ray, CT scan or MRI). You may be offered radiation therapy or chemotherapy if you develop signs or symptoms that the cancer has come back or if your doctor thinks that the risk of recurrence is high.

Chemotherapy may be offered after surgery for stage 1 non-seminoma if your doctor thinks the risk of recurrence is high or if cancer cells were found in the lymph nodes that were removed with an RPLND. Chemotherapy is given through a needle in a vein (intravenously). You may be offered the chemotherapy combination BEP (bleomycin, etoposide and cisplatin).

Find out more about surgery, active surveillance and chemotherapy for testicular cancer.

Surgery is the first treatment for stage 2 non-seminoma. An orchiectomy is done. An RPLND may be offered after an orchiectomy if there are less than 5 enlarged lymph nodes and those lymph nodes are smaller than 2 cm. Lymph nodes may be removed from the side of the body where the tumour was removed or from both sides of the abdomen.

Chemotherapy is a standard treatment for stage 2 non-seminoma testicular cancer. You may have chemotherapy before or after an RPLND. The drugs are given through a needle in a vein. You may be offered one of the following chemotherapy combinations:

• BEP – bleomycin, etoposide and cisplatin
• EP – etoposide and cisplatin
• VIP – etoposide, ifosfamide and cisplatin

The combination of chemotherapy drugs used depends on the tumour’s prognosis. Tumours are grouped according to the International Germ Cell Cancer Consensus Group classification system. Tumours in the good prognosis group may be treated with BEP or EP. Tumours in the intermediate prognosis group may be treated with BEP or VIP. When bleomycin affects the lungs or there is a high risk that it will cause lung damage, EP or VIP may be used instead of BEP.

Find out more about surgery and chemotherapy for testicular cancer.

Surgery is the first treatment for stage 3 non-seminoma. An orchiectomy is done.

Chemotherapy is a standard treatment for stage 3 non-seminoma. It is usually given after an orchiectomy. You may have chemotherapy before surgery if the cancer has already spread and doctors have confirmed the spread is non-seminoma by doing a biopsy. Chemotherapy is given through a needle in a vein. You may be offered one of the following chemotherapy combinations:

• BEP – bleomycin, etoposide and cisplatin
• VIP – etoposide, ifosfamide and cisplatin
• EP – etoposide and cisplatin

The combination of chemotherapy drugs used depends on the tumour’s prognosis. Tumours are grouped according to the International Germ Cell Cancer Consensus Group classification system. Tumours in the good prognosis group may be treated with BEP or EP. Tumours in the intermediate prognosis group may be treated with BEP or VIP. When bleomycin affects the lungs or there is a high risk that it will cause lung damage, EP or VIP may be used instead of BEP. If the cancer has spread to the brain, chemotherapy using VIP is usually offered.

After chemotherapy, the healthcare team will follow up to look for any cancer that remains (called residual disease) and check tumour marker levels. You will have surgery to remove any remaining cancer that is larger than 1 cm. An RPLND may be part of that surgery. You may also have surgery to remove cancer that is outside of the retroperitoneum, such as in the lungs or mediastinum.

Find out more about surgery and chemotherapy for testicular cancer.

Recurrent non-seminoma means that the cancer has come back after it has been treated. If non-seminoma cancer comes back after treatment, it usually happens in the first 2 to 3 years after diagnosis or initial chemotherapy. The following are treatment options for recurrent non-seminoma.

Chemotherapy is the main treatment for recurrent non-seminoma. The combination of chemotherapy drugs given will depend on the treatments that were used to treat the original cancer.

If you were given radiation therapy after surgery to treat the original cancer, you may be offered BEP, EP or VIP for recurrent non-seminoma.

If you were given BEP or EP to treat the original cancer, you may be offered a different chemotherapy drug combination. This is called salvage chemotherapy. You may be offered one of the following combinations, given through a needle into a vein:

• TIP – paclitaxel, ifosfamide and cisplatin
• VIP – etoposide, ifosfamide and cisplatin
• VeIP – vinblastine, ifosfamide and cisplatin

You may be offered high-dose chemotherapy with carboplatin and etoposide if testicular cancer comes back after being treated with standard-dose chemotherapy or salvage chemotherapy. After high-dose chemotherapy, a stem cell transplant is done to replace the stem cells that were damaged or destroyed by high-dose chemotherapy. The stem cell transplant uses stem cells from your own blood (called an autologous peripheral blood stem cell transplant).

Chemotherapy can also be used as palliative therapy for cancer that comes back after having most other treatments. Palliative therapy is given to relieve symptoms rather than to treat the cancer itself. Palliative chemotherapy that may be used for non-seminoma includes:

• etoposide given by mouth (orally)
• gemcitabine with oxaliplatin or paclitaxel given through a needle in a vein

Surgery may be done after salvage chemotherapy or high-dose chemotherapy with a stem cell transplant. An RPLND may be done if the cancer comes back in the retroperitoneum after active surveillance or previous chemotherapy for stage 1 non-seminoma. Surgery may also be done to remove a non-seminoma if it comes back more than 2 years after the original cancer was treated.

Find out more about chemotherapy and surgery for testicular cancer.

Talk to your doctor about clinical trials open to people with testicular cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.