Take Care of Post-Testicular Cancer Mental Health
We often think about the physical effects and consequences of undergoing cancer treatment, and then, perhaps, how they can affect the mind. But the brain suffers in multiple ways even when a person enters remission and joins the ranks of testicular cancer survivors.
"There are definitely important aspects to consider as it pertains to mental health and testicular cancer survivorship for a few reasons," said Nirmish Singla, M.D., M.Sc., the director of translational research in genitourinary oncology at Johns Hopkins Medicine in Baltimore.
Testicular cancer is unique in its impact on young men, as well as its nature as a fairly treatable form of the disease. While the loss of at least one testicle is common, this surgical intervention is actually considered the least invasive option compared to ongoing chemotherapy and radiation.
Regardless of the form of treatment, however, surviving testicular cancer often means coping with significant new realities as part of the recovery and post-recovery process.
"There's the aspect related to body image," said Singla, who is also an assistant professor of urology at Johns Hopkins. "In many cases, you lose a testicle, and now you go from having two testicles to having one, so there are body-image issues related to that, especially as the young adults are getting into relationships or trying to get into that part of their lives."
For many such men, the thought of compromised fertility can be disheartening, and that holds especially true for those in the phase of their life when starting a family is top of mind.
Physicality and fertility are likely two of the aspects that come to mind when people think about testicular health, but have you considered how your genitals might be connected to your brain?
The cognitive effects of cancer
Tracy D. Vannorsdall, Ph.D., an associate professor of psychiatry and behavioral sciences at Johns Hopkins, emphasized that cognitive impairments are also an important aspect to consider during recovery from testicular cancer.
"We know that in men with testicular cancer, a fair proportion will experience, certainly, emotional distress during the time of their diagnosis and treatment," she said, adding that this distress can be part of a behavioral mural that also includes impediments to thinking and brain function. "Cognitive difficulties are often present during cancer treatment, including in those who require surgery as well as those who get radiation and chemotherapy."
Cognitive difficulties tend to manifest at relatively the same rate regardless of the form of treatment, according to Vannorsdall, but the severity of cognitive impairment does fluctuate on a case-by-case basis. In other words, some men may respond more significantly to the surgery itself or the possible radiation to which they are exposed, but variances in cognitive function can't be directly traced to any singular treatment over others.
For the most part, these cognitive issues linger for a while after recovery from cancer is achieved, but the impact on the brain usually eventually dissipates over time.
"What we tend to see is that patients will have real difficulties most severely during their treatment, and they tend to sort of rebound at variable rates during the next year or two," Vannorsdall said.
Understanding where actual cognitive impairment occurs versus perception of such a condition is another matter, however.
Cognition wrapped in blurry lines
"One in 5 men will continue to report cognitive difficulties—subjective or perceived cognitive difficulties—for sometimes years after their treatment. And that tends to be associated with how much emotional distress they are experiencing," Vannorsdall said. "So it's a bit of a chicken and egg. Are you distressed because you're not thinking well or are you not thinking well and the emotional stress is more etiologically tied in?"
She added that clinicians can measure cognitive functioning objectively by performing tests and doing lab work to evaluate whether a patient is suffering from an actual impairment or a perceived functional problem due to emotional or psychological distress.
"So those [tests involve] bringing guys into the lab or into the clinic and having them undergo cognitive testing to see really how their brain is functioning—not just their perception of their thinking skills, but really measuring how their thinking is objectively performing," Vannorsdall said.
These tests frequently reveal that patients aren't just experiencing cognitive distress in an abstract sense, but that their actual computing and mental processing abilities are at a loss of some kind. A fair number of testicular cancer survivors experience persistent difficulties with learning, memory and thinking speed.
Coping with the trauma element
While potential cognitive functioning problems present a big challenge to patients and their medical team on their own, patients also face the emotional toll of cancer treatment and the reality of losing a testicle or two to the illness.
"We do offer testicular prostheses, as well, to patients who wish to have them, but there is only so much you can do to replicate a normal testicle," Singla said.
Prosthetic replacements provide men with an aesthetic surrogacy to the missing organ, but, unfortunately, insurance often doesn't cover them, so the cost can be high.
There's also a traumatic aspect to testicular cancer: strong anxiety correlated to lifelong cancer surveillance, even for men in remission. Experiencing a disease such as cancer is scary, and once someone has gone through it, the idea of experiencing it again can be linked to anxiety-inducing fear. Fortunately, the recovery and observation periods for testicular cancer have become fairly predictable to modern science.
"The good thing is that with testicular cancer, most of the recurrences tend to happen within the first couple of years, and that conditional probability of developing a recurrence drops off significantly beyond that point," Singla said.
Chemo isn't the culprit
People often connect the cognitive and emotional distresses associated with surviving testicular cancer to the physical experiences of undergoing treatments using chemo and radiation. Most people have heard about the sickness and the debilitating nature of these often lifesaving treatment options, so it's easy to assume they are causally responsible for much of the cognitive and emotional suffering cancer patients experience.
Vannorsdall, for one, would have people rethink this stance.
"I always like to make the point that we, in the scientific and clinical communities, have shifted away from that term 'chemo brain,' because it implies that chemotherapy is the only thing that's really driving our brain changes, and we know that's not the case," she said. "For many individuals, they don't have much choice when it comes to the type of treatment that they need to receive. But there are a number of other things that affect our cognition that we really do have a lot more control over, as well as our emotional functioning."
The language used to describe complex and often nuanced psychological concerns is important. Vannorsdall encourages people to use language that encompasses all the possibilities—not just chemo—pertaining to cognitive impairment in patients recovering from cancer. The right language leaves more room for patients to have their issues confronted and dealt with in effective and meaningful ways.
"We're really saying 'cancer-related cognitive change,' because there are things we can deal with," she said. "We can deal with pain. We can deal with the psychological symptoms that quite often go along with a cancer diagnosis—depression and particularly anxiety in this population is really big—and fear of recurrence."
Testicular cancer treatment options matter
So what can be done about these psychological and behavioral health concerns in patients recovering from testicular cancer? As is so often the case, the focus falls on comprehensive health care with an emphasis on the full range of effective mental health intervention options.
"We know that mental health interventions are effective in men with testicular cancer and in cancer more generally," Vannorsdall said.
Unfortunately, not all patients are going to have the same kind of access to the range of necessary services. It's up to patients and their physicians to advocate for and facilitate these services where they are able and where the services will be most useful.
Vannorsdall said all-out efforts to help patients recovering from testicular cancer can have significant benefits when all the right elements are invoked.
"We really need to be making sure that, for our patients, we're giving a full-court press. We're doing all that we can to improve all of those improvable areas and encouraging our patients to be open to interventions that include mental health interventions," she said. "Nobody wants to see anybody suffering when we know that there are treatments out there that can make them feel better and help them enjoy themselves."
