Health

It Takes Balls

By Donovan Webster; Photographs by Jonathan Kantor


For John Perez, life was good. It was December of 2000, and after several years of grinding labor—working through cooking school and sautéing his way up the food chain of Manhattan's finest restaurants—he'd left his assistant-chef job at a three-star eatery called Zoë to start his own catering house.  At 35 years old, the sturdy, dark-haired Perez was living the life he had dreamed of. Through the fall and winter of 2000, he spent his days jetting around the country cooking up parties and meals for the famous and powerful, a group that included the fashion designer

John Varvatos. Then, in mid-December, during the peak of his fledgling company's holiday rush, Perez's world suddenly became very small.

"I felt this little mass the size of a pea on my left testicle," he says. "I thought, What? That's new. So after I got out of the shower, I told my wife, Marisa."

The following day, Perez consulted his urologist, who performed a series of blood tests. The results came back 90 minutes later. They were positive for a "marker compound" called beta chorionic gonadotropin (beta hCG), which occurs naturally only in the blood of pregnant women and in people with certain cancers, testicular cancer among them.

After the positive beta hCG screen, Perez's doctor ordered a sonogram. The left testicle showed an unusual growth. ("When he found it, the technician shouted, ‘Aha! There's your tumor!'" Perez now jokes.) But with positive findings from the most accurate tests for testicular cancer, the uncertainty Perez had felt for the past day now plummeted into dread.

"By 7 that night," he says, "I had cancer."

A SNEAK ATTACK

While testicular cancer ranks among the rarest forms of the disease—comprising only about 1 percent of all cancers in men—it's the most common one among men age 15-35. Last year, according to the National Cancer Institute in the US, 7,400 American men were diagnosed with it, though those cases were far from equally distributed among the races: Testicular cancer is four times more prevalent in white men than in blacks of similar age, and two times more likely than in Asians.

Doctors may have identified the disease's target demographic, but they've yet to figure out its trigger. "All we know is this: If you had an undescended testicle as a child, your risk of testicular cancer rises 25- to 50-fold, though we don't know the reason," says Jerome P. Richie, MD, a professor of surgery at the Harvard University school of medicine.

Some researchers believe abnormal growth of the testicles in childhood or a rare genetic condition called Kleinfelter's syndrome (a disorder in which males have two X chromosomes and one Y chromosome) may start the cancer, but Dr. Richie—one of the United States's top testicular-cancer specialists—discounts these theories as questionable. Instead, he reiterates that testicular cancer can occur in any young man, regardless of risk factors. "Even a seemingly healthy man can be afflicted with it."

Although we don't know much about what triggers testicular cancer, the prognosis for defeating it has become exceedingly positive. According to Craig Nichols, MD, chairman of oncology at Oregon Health Sciences University in the US, the past quarter century has seen the rate of cure skyrocket. "In the 1970s, only 10 percent to 20 percent of all men diagnosed with metastatic testicular cancer survived," he says. "Today we have about a 95 percent cure rate. A testicular-cancer diagnosis isn't the death sentence it was 25 or 30 years ago."

 

CUT AND RUN


But before any patient can begin to hope for a cure, his doctor has to identify the type of testicular cancer he has. And, unfortunately, there's only one way to find out: Remove the testicle.

Using an outpatient procedure called an inguinal orchiectomy, surgeons make a small incision in the groin a few inches below the belt line and pull the affected testicle up and out. (Picture a large, somewhat misshapen pearl onion.) "We need to take out not only the testicle but also its spermatic cord, which is how the cancer most often spreads to other parts of the body," says Dr. Richie. The good news: Because the cancer travels up the spermatic cord, there's no way for it to spread to the remaining testicle. And that sole survivor is all a man needs to retain normal fertility, sensitivity, and sex drive.

Perez underwent the procedure three weeks after his diagnosis. By this time, he had switched physicians, to specialists George Bosl, MD, and Joel Sheinfeld, MD, at New York City's Memorial Sloan-Kettering Cancer Center.

Perez had good reason to make the jump, says Dr. Sheinfeld—and not only because Sheinfeld got the business. With 7,400 testicular cancers diagnosed a year and roughly 8,000 urologists around the country, a doctor may see only one case a year. "And while an orchiectomy is a pretty straightforward surgical approach," Dr. Sheinfeld says, "the cancer management beyond that step becomes more difficult. You want somebody who has performed all of the treatments sev-eral—if not dozens or hundreds—of times."

Perez agreed. "I wanted treatment by the best. It's like my work as a chef. I do a better job filleting a salmon or preparing a chicken than somebody who does it once a year."

His orchiectomy was a success. (Some men will opt for a prosthetic testicle—saline-filled, like a breast implant—but not Perez. "Dressed, there's no difference. After a shower, when your testes are more pendulous, it becomes more apparent," he says. "I actually like the spare room.")

Dr. Sheinfeld's next step: Determine the type of cancer—seminoma or non-seminoma—and the stage.

The less aggressive of the two types, seminomas usually remain localized and spread slowly; they account for about 35-40 percent of all testicular cancers. Non-seminomas move quickly up the spermatic cord to the lymphatic system and comprise about 60 percent of all testicular cancers.

To help orient doctors toward the best treatment after an orchiectomy, more blood tests are performed. If the cancer is gone, existing blood markers usually drop off significantly or disappear. Doctors also use ultrasound or CT-scan imaging to pinpoint other cancerous growths, and sometimes do further biopsies. Finally, after reviewing all this data, they label, or categorize, the stage of the disease.

In Stage One, the cancer is confined to the testicle; Stage Two cancers have spread to the lymph nodes located at the back of the abdominal cavity and below the diaphragm; and finally, Stage Three cancers have spread beyond the lymph nodes and into other parts of the body, such as the lungs, liver, and brain. This type almost killed Lance Armstrong.

In Perez's case, his pathology report indicated that he had a form of cancer with both seminomas and nonseminomas in evidence. But it was Stage One. "The plan," Perez says, "was just to do regular surveillance, just periodic checkups."

Life, after a distracting detour, was back on the main highway. "It was as if this strange bad dream was finally over," says Perez. "Then, a week after the surgery, I got a phone call. And, well, the bad dream was back."

It was the pathologist. After further review, he discovered that he'd missed something. The nonseminoma cancer had spread and may have entered Perez's lymph nodes.

 

CHEMICAL WARFARE

For those men whose cancer has spread, depending on the type of tumor present, the majority of specialists prescribe a course of chemotherapy. While the particular "recipe" of cancer drugs varies, it always includes a medication called cisplatin.

Widely thought to be the magic bullet against testicular cancer, cisplatin—a platinum-based drug that attacks the DNA of the cancer itself—is the reason so many physicians now believe testicular cancer has become curable. "These days," says Dr. Nichols, "even patients with Stage Three cancers stand a very good chance of being cured, thanks to cisplatin."

There are, of course, drawbacks. Because chemotherapy attacks most of the rapidly growing cells in the body, any area where cells are dividing quickly may be damaged. In some men, this causes hair loss, gum sores, tinnitis, a compromised immune system, and a permanent decrease in sperm production in the remaining testicle. Still, because cisplatin-centered treatments are so successful, most doctors employ them as the first line of defense in non-seminoma cancers.

Localized radiation therapy is also an option, but only for men with the slower-moving seminomas. Finally, for aggressive nonseminomas that have spread to the lymphatic system or beyond, there remains a more absolute option: surgery. Specifically, it's called a retroperitoneal lymph-node dissection, or RPLND, a procedure that saved the comedian Tom Green and figure skater Scott Hamilton.

In this operation, which can take from 2-6 hours, an incision is made from just above the pubic bone to the sternum. Then surgeons examine the abdomen to remove all cancerous-looking lymph nodes and tissues throughout the area. Before surgery is over, the gastrointestinal tract's organs have been examined and moved out of the way, since the abdominal lymph nodes are located deep inside, near the kidneys. Further complicating matters, there's a slight chance that the doctor may damage a hard-to-see nerve that controls ejaculation. Severing this nerve results in permanent retrograde ejacu-lation, a condition that causes ejaculate to go into the bladder instead of toward the penis.

"Most of the surgeons who do RPLNDs are extremely familiar with nerve-sparing techniques," says Dr. Sheinfeld. "But even with the best surgeon, there will still be a period of local discomfort after the surgery, and, for several months to up to two years, the patient may also be unable to ejaculate. Make no mistake, this is a big and involved surgery."

DISSECTING THE PROBLEM


Three weeks after receiving that fateful phone call, Perez was under Dr. Sheinfeld's knife for his own RPLND. His combination of seminoma and nonseminoma placed him in a small, rare group for whom this is the optimal treatment. And while his doctors advised him of all his options, Perez was in favor of the most radical therapy first.

"I just wanted to stay away from chemo and radiation," he says, "because, for me, the side effects were more frightening than the surgery. I also wanted my cancer gone the most 100 percent certain way."

Perez's surgery was over in 5 hours. "I checked in to the hospital and they put me under, split me open from crotch to craw, then looked around and fixed what they found."

It would be three weeks before Perez was finally back up and moving around normally. "I tell ya," he says, "for days after the surgery, every time I stood up I felt like my guts were gonna come tumbling out. Literally, they field-dressed me like a deer." He also recalls that for weeks after the surgery he could feel his innards "sloshing around" as they reattached and settled back inside his body. "It wasn't pretty," he adds. "But I also felt assured of this: The RPLND got all my cancer. After the surgery, I knew I was clean."

His doctors had, in fact, gotten it all. However, since there's a 15 percent chance that cancer will develop in the remaining testicle within the next five years, Perez must continue with his self-exams. Except for this, and that big scar down his belly, the unpleasant journey of John Perez's testicular cancer is now behind him.

And he already knows what lies ahead: Only seven months after the surgery, Perez's ability to ejaculate returned and Marisa became pregnant with their first child.

"We did it naturally and everything," he says. "We had a baby girl in June." 

 

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