8 Things You Should Know About Testicular Cancer

testicular cancer awarenessIn the medical world—and especially the genitourinary (GU) world – we’re pretty comfortable having candid conversations about what’s going on below the belt. After all, the “genito” half of our name refers to diseases of the genital organs. April is testicular cancer awareness month and there’s no need for the testes to be a taboo topic. Awareness is key to early detection, so here are 8 things you should know about testicular cancer:

  1. It can develop in one or both testicles. Our bodies aren’t always exactly symmetrical and the same can be said for cancer development. Just because cancer develops in one side, it doesn’t guarantee that the other testicle will be affected.
  2. You shouldn’t feel pain. Testicular pain isn’t normal. Visit your primary care physician and inquire about getting an ultrasound to get a better picture of what’s going on. You may also need a referral to a urologist.
  3. Self-examinations are important. Make an effort to get in a regular habit and aim for once a month. The more you’re familiar with what’s normal for you, the easier it will be to spot something that isn’t right. Not all lumps and bumps mean cancer, but it is important to get them evaluated.
  4. Certain men are at increased risk. While testicular cancer can affect males of all ages, most new cases occur in men between the ages of 20-34. Other risk factors include men who were born with undescended testes (when the testes don’t move into the scrotum during development), men with Klinefelter’s syndrome (two or more X chromosomes), men with a family history of testicular cancer and certain familial cancer syndromes (inherited cancer genes).
  5. When caught early, most testicular cancer is curable. Testicular cancer has one of the highest cure rates. We have a number of successful ways to treat testicular cancer, including surgery, radiation and chemotherapy. Seek out a specialist for evaluation if you sense something is wrong. A typical initial work up will include an ultrasound and blood tests, and then possibly a CT scan to get a better picture of what’s going on in your body from a variety of different angles.
  6. A diagnosis doesn’t mean you can’t have kids. Most men are able to successfully father children following treatment, but there are occasional situations in which prior history, cancer, or the nature of the treatment can prevent it from happening naturally. Some centers (such as ours) are able to extract sperm, which can be utilized for fertilization. Before starting treatment, ask about your options to preserve fertility, including sperm banking.
  7. It doesn’t signal an end to your sex life either. Following treatment, sexual function should be normal.
  8. Some treatments should only be performed at centers of excellence. For example, in today’s treatment era, some men only need removal of the affected testicle. These men can be spared additional surgery, radiation, and/or chemotherapy that might have been administered in the past, but they remain at risk for tumor recurrence that might be missed in less experienced hands. A type of surgery called retroperitoneal lymph node dissection (RPLND) should only be performed by someone with specialized experience in this procedure. Additionally, certain types of chemotherapy regimens are very complicated and require autologous stem cell support (bone marrow transplant) to achieve cure. We happen to offer all of these specialized approaches.

A version of this article was first published on April 30, 2016. 

Studies Highlight Erdafitinib as an Encouraging Bladder Cancer Treatment Option

It has been an especially exciting time for our Genitourinary (GU) Oncology Program. Our team’s bladder (urothelial) cancer research recently made its way into two prestigious medical journals, with both studies highlighting erdafitinib – an oral inhibitor of fibroblast growth factor receptor (FGFR) – as an encouraging therapeutic option for the disease.

FGFR gene alterations are common in urothelial carcinoma and may be associated with low sensitivity to immunotherapy.

In a phase II study of 99 adults with locally advanced or metastatic urothelial carcinoma harboring FGFR gene alterations, Dr. Scott Tagawa and colleagues found erdafitinib to demonstrate impressive tumor control and tolerability. Forty percent of patients responded to the drug, and among the 22 patients who had previously received immunotherapy without success, the response rate jumped to 59 percent.

Weill Cornell Medicine“While not yet confirmed by randomized trial results, the fact that these patients with the unique molecular tumor selection were responsive to erdafitinib and resistant to prior lines of standard therapy makes this a pivotal study,” said Dr. Tagawa. “It’s wonderful to now have this option available for our patients early while awaiting results of the confirmatory randomized trial. It highlights the importance of genomic tumor testing.”

The research group’s findings were published in the New England Journal of Medicine and led to accelerated approval of erdafitinib as the first targeted drug for urothelial carcinoma from the United States Food and Drug Administration (FDA).

In addition to the use of next-generation sequencing of tumors to more precisely select those most likely to respond, the standard erdafitinib regimen also utilizes individualized dosing. Erdafitinib, partly depending on the dose used, is shown to induce increased phosphorus levels in the blood. As blood phosphorus levels are related to targeting of the key pathway (FGFR), the dose of erdafitinib is increased if phosphorus levels do not significantly increase in the absence of any significant side effect. In a retrospective analysis presented at the 2019 European Society of Medical Oncology (ESMO) annual meeting, erdafitinib-treated patients with increased blood phosphorus levels had improved outcomes.

Under the leadership of Dr. Bishoy Faltas, an in-depth analysis of the nuanced molecular characteristics of upper-tract urothelial carcinoma (UTUC) – an aggressive cancer occurring in the lining of the ureter and kidney – supports that erdafitinib has potential to improve the effectiveness of immunotherapy in this patient population.

Whole-exome and RNA sequencing of UTUC patient tumors yielded a number of insights into the biology of the disease – chiefly that it has low immune cells (T cells) and high expression of FGFR3. The research team found that inhibiting FGFR3 with erdafitinib increased the activity of BST2, a gene associated with immune system activation. Thus, combining FGFR3 inhibitors such as erdafitinib with a class of immunotherapy drugs called PD-1/PD-L1 inhibitors can serve as a viable treatment strategy for UTUC in the future.

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“By inhibiting FGFR3, we are able to stimulate genes that are associated with activation of the anti-tumor immune response,” said Dr. Faltas. “In the future, we could potentially use this strategy to reverse the T-cell depletion in these tumors.”

Findings from Dr. Faltas et al. were published in Nature Communications.

Erdafitinib is under further investigation and development in an ongoing clinical trial at Weill Cornell Medicine and NewYork-Presbyterian.

A Phase 1b-2 Study to Evaluate Safety, Efficacy, Pharmacokinetics, and Pharmacodynamics of Erdafitinib Plus JNJ-63723283, an Anti-PD-1 Monoclonal Antibody, in Subjects with Metastatic or Surgically Unresectable Urothelial Cancer with Selected FGFR Gene

We are proud to draw upon our longstanding expertise in the bladder cancer field to lead advancements in the understanding and care of this disease, and we hope that sharing our findings will prompt additional discoveries.

 

The Pathologist’s Crucial Role in Cancer Care

By Francesca Khani, MD

Some say that in medicine, healing begins with a diagnosis. Pathologists – physicians who work in a laboratory to examine samples of body tissue for diagnostic purposes – play a tremendously important role in determining a patient’s treatment plan, even though they usually do not directly interact with patients.

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Pathologists act behind the scenes, consulted by doctors in other specialties to render a diagnosis so that a patient’s disease can be managed appropriately. Armed with an accurate diagnosis, the treating physician can present the patient with the best therapeutic options.

There are many different types of pathologists, encompassing a wide range of laboratory medicine fields. Anatomic pathologists specialize in evaluating tissue or cell samples from patients and are responsible for diagnosing diseases. Samples range in size from collections of individual cells (such as a pap smear), to biopsies (removal of a small piece of tissue), to entire organs removed during surgery. These cells or tissue samples are traditionally evaluated under a microscope for the diagnosis of a variety of diseases, including cancer.

Pathology at Weill Cornell Medicine and NewYork-Presbyterian Hospital (WCM/NYP) is highly sub-specialized such that each pathologist has disease-specific expertise. In particular, we have multiple pathologists trained in and dedicated to evaluation of genitourinary (GU) malignancies, including prostate, bladder, kidney and testicular cancers.

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In patients suspected to have a GU cancer, pathologic evaluation is critical to initiate a treatment plan (e.g. surgery, chemotherapy, and/or radiation). Accurate assignment of a tumor grade (based on aggressiveness) and stage (based on the extent of the tumor) is essential to determining the patient’s prognosis and informing the most effective disease management plan. Some prostate or kidney cancers, for example, may be indolent (slow-growing) and can be safely monitored without treatment, instead of requiring immediate surgery or radiation treatment.

In some cases, the diagnosis is straightforward and can be determined easily from examining the first set of microscopic slides created from the tissue. In other cases, when the appearance of the tissue under the microscope may be more ambiguous and difficult to interpret, a team of pathologists will work together to reach a consensus on the diagnosis. Sometimes additional testing is necessary, such as the application of special stains that contain antibodies which reveal the presence or absence of certain proteins, aiding pathologists in determining the correct diagnosis. Other testing examines the genetic profile of the tissue. At WCM/NYP, we routinely perform a comprehensive genetic characterization of a patient’s tumor, which can inform next steps if actionable molecular targets are identified.

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GU pathologists at our institution implement a highly collaborative approach to patient care and are in close, constant communication with colleagues in urology, medical oncology, radiation oncology and beyond to discuss the nuances of individual patient cases. These discussions take place at regularly scheduled multidisciplinary meetings and as needed throughout our work. Open lines of communication among the various GU physician stakeholders truly helps to optimize care for people with these diseases.

The GU Oncology Program’s commitment to excellence runs deep – behind the scenes and beyond the exam room. Our pathologists’ hard work to secure the right diagnosis pays off in dividends when it puts patients on the fast track to receive the treatment most likely to act against their disease and produce the best health outcomes.