Treatment Plan

Dr. Hanna at IU has recommended surveillance (repeated CT scans with no upfront chemotherapy). This carries a 70% chance of recurrence followed by a more intensive chemotherapy regimen, but helps ensure that the cancer isn’t under or over treated.

Ali and I flew out to Indianapolis to visit IU’s oncology department. IU treats a very significant portion of testicular cancer cases in the country and has a great understanding of both the science and statistics of how to treat cases like mine. Going in it was my understanding that my CT scan was clean and the oncologist would recommend either surveillance (with a significant chance of recurrence) or one round of BEP (with a 2-3% chance of recurrence).

Dr. Hanna surprised me by focusing on an aspect of my CT scan that I had previously glossed over. The chest scan showed several small subpleural nodules in my lungs that were favored to be benign. My brother said these very common and it was unlikely that they are related. Apparently they are particularly common among those who grew up in the midwest due to a condition called Histoplasmosis. This is a fungal disease that leaves behind small, benign non-calcified structures in multiple locations of both lungs.

Dr. Hanna, however, is concerned that if these spots are embryonal carcinoma and they are ignored we could make my case far more difficult down the line. It is unlikely, although not impossible, that the embryonal carcinoma would exhibit in the lungs without appearing anywhere else in my CT scan. Thus, he said I have either a high risk Stage 1 cancer or a low risk Stage 3 cancer. If he were to suggest one round of BEP upfront and the spots on my lung are embryonal carcinoma, we would be severely undertreating the disease. This would be insufficient to remove the cancer and would instead have the negative effect of making the remaining cancer particularly resistant to chemotherapy.

The only way to determine definitively if the nodules are benign is to monitor them with follow up CT scans. If CT scans over these next two months do not show any growth in the nodules, we will know that they were not embryonal carcinoma. Unfortunately, during this time there is a chance that any microscopic spread of the cancer to my lymph nodes will also have a chance to develop. This growth would no longer be able to be cleared with a single round of BEP chemotherapy. This means that if the first CT scan does not show any progression in the lungs I will have to go in for continued surveillance to determine if the cancer has spread on a macroscopic level to my lymph nodes. If it does, I will have three rounds of chemo.

Based on the risk factors present in my case (a highly malignant embryonal carcinoma with vascular invasion) and IU’s as yet unpublished internal statistics, there is a 70% chance of recurrence. This sounds bad, but Dr. Hanna’s main point was that for many years testicular cancer has been consistently overtreated out of an abundance of caution. Choosing surveillance means that we can avoid undertreating Stage 3 cancer and maintain a 30% chance of avoiding chemotherapy and its side effects altogether. Whether chemotherapy is performed upfront with 1 round or after recurrence with 3, he emphasized that there’s a 99% chance that I’m going to be fine.

I’m not terribly happy that there’s a 70% chance I’ll be getting three rounds of chemo, but I’m confident it’s the right decision. I had expected Dr. Hanna to say I had the option of surveillance or one round of chemo upfront if I decided I was uncomfortable with the prospect of waiting. I understand Dr. Hanna’s point that testicular cancer is routinely overtreated. Furthermore, I absolutely don’t want to do anything to jeopardize a 99% chance of recovery by undertreating and ultimately strengthing a cancer that has already spread somewhat significantly. This route sounds like it may take a little longer than I had hoped but does the best job of making sure this remains a manageable problem.

Ultimately, it’s now just a matter of odds. Over the next two months I’ll gain an understanding of whether the pulmonary nodules are benign (which I expect they will be). After that I will learn if microscopic cancer remnants in my body have spread through my lymphatic system. There is a 70% chance of this occuring. The mean time of recurrence for a case like mine is 6 months. If after two years no cancer has recurred the overwhelming likelihood will be that I am cancer free. With 70% odds I was told to prepare myself for three rounds of chemo down the line. Over the next month or two, however, I’m looking forward to not having to go in for constant appointments!