For this interview in honor of Testicular Cancer Awareness Month, Dr. Sam Kaffenberger, an Assistant Professor of Urology at the University of Michigan Health System, explains the importance of taking a nuanced approach to the management of individual patients with testicular cancer, with the goal of minimizing toxicity and achieving the best possible outcomes for treatment and surgery.
This interview has been conducted in partnership with the American Urological Association, a premier urologic association, providing invaluable support to the urologic community. Their mission is to promote the highest standards of urological clinical care through education, research, and the formulation of health care policy.
Oncology Data Advisor: Welcome to Oncology Data Advisor. For this interview in honor of Testicular Cancer Awareness Month, I'm joined by Dr. Sam Kaffenberger.
Sam Kaffenberger, MD: I'm Sam Kaffenberger. I'm one of the urologic oncologists here at the University of Michigan, at the Rogel Cancer Center here. I've been practicing for about six years now. I did my residency at Vanderbilt University in Nashville, and I did my fellowship at Memorial Sloan Kettering in New York City. I have been on faculty here since 2016. I specialize in testis cancer, as well as other complex retroperitoneal surgeries. One of my big clinical interests is improving the care of patients with testis cancer.
Oncology Data Advisor: So, in personalizing treatment for patients with testicular cancer, what are some of the factors that should be considered?
Dr. Kaffenberger: I think every patient that we see with testis cancer is somewhat unique. This is a cancer usually of young men, although not always. Therefore, there are some special considerations that are always in play in terms of fertility preservation. The name of the game in testis cancer—because it's been so successful over the years, thanks to the efforts of many before—is trying to minimize toxicity of treatment. You're doing the least amount possible to make sure that patients get cured.
Therefore, a nuanced approach is really important for each individual patient. We try to do everything we possibly can to make sure that each patient gets the exact guideline-concordant treatment. For the folks who are taking care of patients in testis cancer, there really is some true nuance in the management of these patients. These are things such as, for patients who come in with elevated tumor markers after the orchiectomy, making sure that you give them time for their markers to go as down as far as possible before moving on to the next step in therapy. These are critical things because we may jump too soon to give too many treatments otherwise.
A lot of this also making sure that we offer patients the option for fertility preservation or sperm preservation prior to embarking on certain treatments like chemotherapy and surgery afterwards. For most patients with testis cancer, they present with stage I early on in the disease, and most are cured with just removal of the testicle by itself. For everyone else, we just have to make sure that we're doing the right thing by these patients. I tell all the patients who come see me that second and third opinions are always a good thing, even the ones who are seeing me for the first time. Having patients seen at a high-volume center is sometimes helpful, just to make sure that they're on the right track. Individualized approach is key for testis cancer.
Oncology Data Advisor: Thank you. So, what are some of the new investigations that are underway in testicular cancer surgery?
Dr. Kaffenberger: The big things that have been in discussion for a lot of urologic cancers, and probably a lot of surgery in general, is the involvement of minimally invasive surgery—and even the step before that, trying to select the patients who actually need this surgery. For the patients with stage I testis cancer, there are a number of things that are under investigation, including microRNAs, like microRNA-371, which are trying to predict which patients have disease and which patients don't at the time of surgery. Because there's no question that if we're doing surgery for patients at stage I, there are a large number of patients who are overtreated by definition, even patients with higher-risk disease. For patients with stage IB disease, who have maybe a 50% chance of having a relapse, that still is 50% of patients who are being overtreated with surgery.
Ultimately, our goal is to cure everybody. The second goal is to prevent some of the long-term toxicities that come with things like chemotherapy. It's also true that surgery itself carries risk, and we want to minimize it to the best of our ability to do so. That's where some of the new things like microRNAs come into play. That's an exciting area; there are clinical trials that are ongoing for this. I think that's probably the future, in addition to the current tumor markers that we have.
When we go to the actual form of surgery itself, then the question becomes, "Is there a role for the use of minimally invasive or robotic surgery?" I think it's critical that this is done by experienced surgeons. I think it's also critical that we make sure that we maintain the concepts that are in place for good open surgery. Where we can really hurt individual patients is if we do inadequate surgeries. The lymph node dissection has to be just as thorough as it is with open surgery. If we're talking about sparing nerves for fertility preservation or to prevent retrograde ejaculation, the same concepts have to be in place for robotic surgery. Obviously, we urge caution. From a quality-of-life standpoint, I think it does offer some benefits.
For those of you who have done robotic surgery for retroperitoneal lymph node dissections, these patients commonly go home on Day 1. There's no question that they have less pain afterwards and less time in the hospital, and experienced hands can probably have similar outcomes to open surgery. Patient selection, as for anything else, is key. For patients with bigger masses after chemotherapy, when we're doing post-chemotherapy retroperitoneal lymph node dissections, a lot of these can still be done robotically. Again, the same concepts have to be in play for meticulous dissection: taking the time to really clip the lymphatics, sparing the nerves when possible, and making sure that we take care of the surrounding structures, the ureters, other arteries to the kidneys, and the bowel that's close by.
In experienced hands, you can probably have similar outcomes. But in my opinion, this is a surgery that ought to be done with folks who have good experience doing it and who do more than just one or two per year. Again, these are young guys that have many years left to live; we want to make sure they get cured with the minimal amount of toxicity or morbidity. That's sort of my thought here. If you ask my thoughts of what the future looks like for surgery for this, I do think that robotics plays a role, especially for stage I patients doing adjuvant surgery or easy teratomas for folks who are post-chemotherapy.
Robotic surgery can really improve through proof of patients and through the hospital system, making their time easier, leaving smaller scars, and things like that. That does have a role for younger men. I think we can do as good a job, but we just have to make sure that we're thoughtful about how we do it.
Oncology Data Advisor: Great, thank you. So, with all these new approaches, do you have any advice for members of the cancer care team about how to manage the side effects of treatment and surgery?
Dr. Kaffenberger: I think it's kind of a broad question in terms of managing side effects; I think medical oncologists in general do a great job of taking care of patients with testis cancer and getting them through the chemotherapy. One key thing is making sure that patients are getting the right chemotherapy and the right amount of chemotherapy, and that's where some experience comes in. Every case is a little bit individualized in making sure that we let the markers have time to nadir, really trying to select which patients get four cycles of BEP (bleomycin/etoposide/platinum) versus three cycles of BEP. I think that's probably the biggest part of minimizing toxicity with chemotherapy.
Some of the longer-term side effects are, to some extent, unavoidable for the folks who really need treatment for testis cancer. Guys who present with metastatic testis cancer need the chemotherapy, and some of the long-term side effects are unavoidable. I counsel all my guys with testis cancer to make sure that they do the best that they can to protect their bodies long-term: not to smoke, healthy eating, exercise, appetite, things like that.
We know that platinum's not good for the cardiovascular system; when these guys get heart attacks, they get them a decade sooner than the general population. Even primary care doctors who are taking care of patients who've had testis cancer in the past, have to be aware of this—especially if they have other risk factors added on, such as family history or smoking. Maybe a young guy who comes in with chest pain might actually be having a heart attack. We really have to think about the longer-term consequences; same thing for secondary cancers that can be caused by the etoposide and things like that.
By and large, the medical oncologists at both the community and the academic centers do a great job at taking care of these guys. Most of these patients are young, they're resilient, they're tough; but beyond the direct toxicities of chemotherapy, with regards to surgery, I really put effort in trying to preserve the nerves to preserve core flow of ejaculation wherever possible. It's a lot easier to not do a nerve-sparing surgery; it saves quite a bit of time during surgery. It's a tedious dissection, but I think we're doing patients a disservice by not doing a good nerve sparing during a retroperitoneal node dissection, assuming that it's doable from a disease control standpoint. From a surgical side, I think robotic surgery probably does help manage some of the side effects, especially the short-term discomfort, pain, and time in the hospital.
The critical side effects that we talk about for surgery in the short term are things like lymph leaks or chylous ascites. I encourage all of our clinicians who are taking care of this to do meticulous clipping. At the University of Michigan, we do a low-fat diet for about a month and a half afterwards to try to reduce the risk of having a lymph leak afterwards. There's not good data to support that, so when I see guys back at three or four weeks afterwards and they haven't had signs of lymph leak, I usually relax that diet pretty quickly. The times that we see this, at least in my experience, have been in the first couple of weeks. The other thing I try to avoid doing whenever possible is to not take the IMV, or inferior mesenteric vein, during surgery, but again, just totally anecdotal.
Those are some of the short-term things. In the long term, of course, we worry about the long-term retrograde ejaculation that we already talked about, and then of course, the lifelong risk of small bowel obstruction. Otherwise, in general, the folks who are oftentimes getting these surgeries are young and do shockingly well after a surgery. I think it's a big surgery to go through. It's daunting for patients, but I think, especially in experienced hands, the surgery goes really well. The vast majority of the time, guys are back on their feet and doing what they were doing beforehand. It's oftentimes a big success story, which is great news for patients with testis cancer.
About Dr. Kaffenberger
Sam Kaffenberger, MD, is an Assistant Professor of Urology at the University of Michigan Health System and the Medical Director of the Rogel Cancer Center Ambulatory Care Unit. He specializes in the treatment of patients with urologic malignancies, including testicular, prostate, kidney, penile, adrenal gland, and bladder cancers. Dr. Kaffenberger's research focuses on translational oncology, cancer genomics, and prostate cancer screening, with the goal of improving the prevention, detection, and outcomes of patients with urologic malignancies.
For More Information
Ahmadi H, Jang TL, Daneshmand S & Ghodoussipour S (2021). MicroRNA-371a-3p as a blood-based biomarker in testis cancer. Asian J Urol, 8(4):400-406. DOI:10.1016/j.ajur.2021.08.004
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.
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