Cut down in their prime

Men
between the ages of 25 and 35 are most at risk of testicular cancer. The OH
nurse is in an ideal position to raise awareness of this potentially
embarrassing condition and to give support after a diagnosis is made and
treatment started. By Nic
Paton

Testicular
cancer is not a common cancer. It accounts for just 1 per cent of cancers in
males, with about 1,400 new cases diagnosed each year, according to a recent
study in the BMJ1. The cure rate, if it is caught reasonably early, is high, at
about 95 per cent. But what is important for occupational health professionals
is that the disease predominantly affects white, northern European men aged
between 15 and 40, with those most at risk aged between 25 and 35. In other
words, men of prime working age.

Dr
Robert Huddart is co-author of the BMJ study, and senior lecturer and honorary
consultant in clinical oncology at the Institute of Cancer Research and the
Royal Marsden NHS Trust. He estimates the overall risk rate of developing
testicular cancer is one in 400. So, in a workforce of 1,000 men, an
occupational health nurse could find she or he is dealing with two cases at any
one time.

"The
average working population is more male-orientated. Therefore it is potentially
the most common form of cancer you will get in the workplace. The message needs
to be that it is the commonest cancer in that age group," Dr Huddart says.

Symptoms

Testicular
cancers, or germ cell tumours, are growths that occur in the sperm-producing
cells of the testes. The most common symptom is a painless swelling or lump in
one testis. Some men experience a dull ache or feeling of heaviness in the
lower stomach, scrotum or groin. Other symptoms can include backache and
breathlessness.

Monthly
testicular self-examinations can help spot the condition early on, with
examinations best done after a warm bath or shower when the skin of the scrotum
is relaxed.

Awareness
of testicular cancer has improved dramatically since the 1970s, as have
survival rates. Government statistics for England and Wales published in
February found that, in the latter half of the last century, the number of
cases of testicular cancer almost doubled, but mortality fell dramatically.

Research
published in The Lancet2 in June showed that the UK had seen one of the biggest
falls in deaths from testicular cancer in the world over the past 20 years.
Comparing mortality rates between 1975 to 1979 and 1995 to 1997, UK rates had
fallen by 72 per cent, with only Sweden seeing a greater fall. It is suggested
that the reasons were improved awareness and increasing use of more powerful,
platinum-based chemotherapy.

But
there is no reason to be complacent, particularly in the workplace, argues Dean
Linzey, clinical nurse specialist in men’s services at South East Essex
Community and Mental Health Trust. Linzey disputes the idea that mortality
rates are dropping. He estimates that while eight or nine years ago there were
about 100 deaths from 1,400 new cases a year, last year it was more like 200
deaths from about 2,000 new cases.

"The
problem with testicular cancer is that it does not necessarily hurt. If you
wait until it is hurting, then it has almost certainly metastasised," he
says. "The real importance is in getting in there at an early stage and
that is really where the primary carer and OH nurses have something to offer."

When
it comes to talking about self-examination in the workplace, it is a good idea
to assess what sort of language will be most effective. For instance, a
provocative and humorous campaign may help to raise interest among younger men
but might not be so appropriate for older colleagues.

Magazines
such as Men’s Health, FHM and GQ often run testicular cancer campaigns. Cancer
charities can help too. Whatever the source, occupational health professionals
need to ensure they have reliable, up-to-date and accessible information on the
condition.

Raising
awareness can extend from sticking up posters on the occupational health notice
board to running face-to-face health awareness days, suggests Peter Gill,
clinical nurse specialist in male urological cancers at Velindre Hospital NHS
Trust in Cardiff. OH nurses also have a key role to play when it comes to
referral to a GP.

"Because
testicular cancer is not like a common breast lump, and GPs may not even have
seen one before in their career, we find there can be delays as they sometimes
treat it with antibiotics. But if the OH nurse sends them, the GP will often
listen more than if the person had gone on his own," he says.

Macmillan
nurse specialist Antonia Dawson suggests placing information and leaflets in
men’s toilets, so men can pick them up without being seen. "You need to
put leaflets where people are going to pick them up."

Treatment

Once
an employee has been diagnosed and undergone treatment – most commonly an
operation to remove the affected testicle – further issues arise. The
operation, follow-up treatment and recovery time should see employees back at
work after two to three months, but the physical recovery is just one part of
the process.

"There
is going to be a problem of body image," says Linzey. "We live in a
very phallocentric society where our balls are very important. So you need to
have very much an open door approach. There could also be issues of depression,
questions of mortality and fertility and worries about their future. They might
feel no longer a man but half a man.

"You
may get a grounded guy who laughs it off and then see aspects of their psyche
showing through at a later stage. So you need to consider counselling and
support," he adds.

The
OH nurse also has a vital part to play in ensuring employees are given the time
off to attend their follow-up appointments over the next two years, and that
they turn up at all. Some 5 per cent of men will develop a tumour on their
other testicle, estimates Gill, so maintaining follow-up is critical.

The
OH nurse is well placed to maintain friendly contact with the employee after
his operation, offering advice and support, and showing his employer has not
forgotten him, adds Dawson.

Some
men will need hormone replacement therapy to cope with reduced sex drive and
lower energy levels. There may also be permanent numbness around the scarred
area. If the cancer is more severe, it may be that a course of chemotherapy,
which lasts up to three months with six weeks recovery time after that, is
needed. And if it has spread, there may need to be a further, more substantial
operation.

Returning
to work

On
a practical level, it is wise to ensure a worker is put on lighter duties for
the first few weeks after he returns if his work is of a manual nature, argues
Gill. Fatigue is the biggest symptom suffered by those returning to work after
cancer, so ensuring he has enough breaks is important.

Workers
may also want to look at the possibility of returning part-time on an initial
basis.

Then
there is the issue of the environment to which the worker is returning. A
survey by Macmillan Cancer Relief, published in July, found more than half
those people with cancer polled said their co-workers had little or no
knowledge of the disease, its treatments or side effects. About one in five (21
per cent) felt their bosses had reacted negatively to the news, while 13 per
cent said it had been made clear they were to maintain their usual workload.

And,
adds Dr Huddart, a recent survey of more than 700 long-term survivors of
testicular cancer found a high proportion felt their job prospects had been
affected, particularly when it came to promotion.

Talking
to line managers about the condition, its implications and the long-term
outlook, are a crucial part of the OH nurse’s support role, he argues.

"It
is important to get the message across that this is a very curable illness and
most men will go on to have a normal working life after this. For most men it
is a temporary blip in their career," he says.

References

1.
Dearnaley DP, Huddart RA, Horwich A, BMJ, 322:1583-1588.

2.
Levi F, La Vecchia V, Boyle P, Lucchini F, Negri E

The
Lancet, 357(9271): 1851

www.statistics.gov.uk/pdfdir/crt0201.pdf

www.bmj.com

www.thelancet.com

www.cancerbacup.org.uk

Macmillan
Cancer Relief: 020 7840 7841

Institute
of Cancer Research: 020 7352 8133