Testicular cancer: recognition and management in AU general practice

Testicular cancer is the most common malignancy affecting Australian men aged 18–39, yet it is also one of the most curable solid tumours in medicine. AIHW data (2024) records roughly 860 new cases each year — a lifetime risk of about 1 in 200 for Australian men — against only about 25 deaths annually. That extraordinary gap between incidence and mortality reflects how profoundly germ cell tumours (GCTs) respond to platinum-based chemotherapy. Even men with disease that has spread to distant organs have a 5-year relative survival around 73%; for disease confined to the testis it exceeds 97%.

The single greatest clinical challenge is late presentation. The median delay between noticing a lump and receiving a diagnosis in Australia is 3–4 months, according to Cancer Council Australia. The GP who recognises an intratesticular mass early, acts on the same day, and refers urgently to urology directly determines whether a young man is cured with orchidectomy alone or requires prolonged chemotherapy. This article covers the recognition, triage, and long-term survivorship role of the GP — the parts of testicular cancer care where general practice makes the most difference.

A. Core clinical — the AU general-practice framework

Recognition

The classical presentation is a firm, painless testicular lump or unilateral enlargement — found incidentally in the shower or after minor trauma that draws attention to the area. About 20% of cases present with dull aching rather than a mass, and up to 10% have a reactive hydrocele that can obscure the underlying tumour on examination.

Features that should raise suspicion alongside a lump:

• Heaviness or dragging sensation in the scrotum or groin
• Gynaecomastia (from β-hCG secretion by the tumour)
• Persistent back pain (suggesting para-aortic lymphadenopathy)
• Unexplained cough or breathlessness (pulmonary metastases)
• Left supraclavicular lymphadenopathy (Virchow’s gland — testicular lymphatics drain to the para-aortic chain, which communicates with the thoracic duct)

Risk factors worth eliciting in any young man attending for a scrotal concern:

• History of cryptorchidism — confers a 4–8× lifetime risk, even after orchidopexy
• Personal history of a previous testicular GCT (~1–2% cumulative annual risk on the contralateral side)
• First-degree family history of testicular cancer (~4–6× relative risk)
• HIV, Klinefelter syndrome, or sub-/infertility
• Known germ cell neoplasia in situ (GCNIS) on prior biopsy

Examination

Examine both testes with the patient supine then standing, comparing sides. A mass arising from within the testis itself (not separable from it) is malignant until proven otherwise by ultrasound. Trans-illumination with a pen torch distinguishes a simple hydrocele (transmits light) from a solid mass (does not). Always examine the contralateral testis, the abdomen for palpable retroperitoneal mass, the supraclavicular fossae, and check for gynaecomastia (true glandular breast tissue under the areola, not adipose tissue).

Do not assume an acute or painful presentation excludes cancer: about 20% of testicular GCTs bleed internally and present with sudden pain indistinguishable from torsion.

First-line investigations (order before referral)

Per Cancer Australia 2024 and EAU Guidelines 2024, the GP should initiate:

1. Scrotal ultrasound — high-resolution (≥7.5 MHz) with colour Doppler; sensitivity >99% for intratesticular mass. MBS item 55059 (scrotal contents).
2. Serum tumour marker triad — order all three before any treatment:
   • β-hCG quantitative (MBS 66608)
   • AFP (MBS 66711)
   • LDH (MBS 66660)
3. FBC, UEC, LFTs (MBS 65070, 66512) — baseline organ function.

Critical pitfall: negative markers do not exclude cancer. Approximately 40% of pure seminomas and 10% of non-seminomatous GCTs (NSGCTs) have all three markers within the normal range at presentation. Ultrasound-confirmed intratesticular solid mass must be referred regardless of marker results.

The one thing never to do: do not arrange trans-scrotal biopsy or fine-needle aspiration. The testis drains lymphatically to the para-aortic nodes; trans-scrotal violation diverts drainage to inguinal nodes, altering staging anatomy and potentially mandating inguinal irradiation that would otherwise be unnecessary. Diagnosis is established by radical inguinal orchidectomy — the definitive diagnostic and therapeutic procedure (EAU 2024).

Referral

Request an urgent urology appointment within two weeks via the state suspected-cancer pathway. If any delay is anticipated, telephone the on-call urology registrar directly. Document the clinical examination, ultrasound request, marker results, and referral timing in the medical record — delayed diagnosis of testicular cancer is a recognised medicolegal risk.

Sperm cryopreservation

Before orchidectomy and certainly before any chemotherapy or radiotherapy, discuss sperm banking and provide a referral to a fertility clinic. About 60–80% of men recover adequate spermatogenesis by two years after chemotherapy, but a meaningful proportion remain azoospermic (Brennemann et al, Andrologia 2009). The pre-treatment window is the single best opportunity; banked sperm gives reliable access to ICSI later. This discussion should be documented — failure to offer is a recognised source of patient complaint. Sperm cryopreservation is not currently MBS-rebated for cancer-related fertility preservation; the private pathway is typically $400–800 for retrieval plus annual storage.

B. Histology, staging, and what the markers mean

The two main types

Germ cell tumours account for approximately 95% of testicular cancers and fall into two clinically important categories:

Seminoma (peaks age 30–50): AFP is never elevated in a pure seminoma. β-hCG is mildly elevated in 15–20%. These tumours are exquisitely radiotherapy-sensitive and respond well to lower doses of cisplatin-based chemotherapy. Prognosis is excellent at all stages.

Non-seminomatous germ cell tumour (NSGCT) (peaks age 15–35): embryonal carcinoma, yolk-sac tumour, choriocarcinoma, teratoma — alone or as mixed histology. AFP is elevated whenever yolk-sac elements are present. β-hCG can be very high in choriocarcinoma. NSGCTs are radiotherapy-resistant and more aggressive, but highly chemotherapy-sensitive. Critically: a tumour reported as “pure seminoma” by the pathologist with an elevated AFP must be reclassified and treated as NSGCT — a single yolk-sac element may not have been sampled.

Testicular lymphoma (diffuse large B-cell lymphoma predominates) accounts for most testicular malignancy in men over 60 and requires haematology referral.

What the AJCC staging means for the GP

Per the AJCC 8th edition TNMS system:

• Stage I — disease confined to the testis; about 70–80% of men at diagnosis
• Stage II — spread to retroperitoneal lymph nodes
• Stage III — distant metastases, or persistently elevated post-orchidectomy markers

The unique “S category” reflects post-orchidectomy tumour-marker nadir — failure of AFP and β-hCG to fall at their expected half-lives (AFP 5–7 days, β-hCG 24–36 hours) indicates residual disease and upgrades staging even without imaging evidence of spread.

C. Treatment — what the oncologist does and why it matters to the GP

Treatment is coordinated through a urology / medical oncology / radiation oncology multidisciplinary team, with protocols from eviQ and ANZUP. The GP’s literacy in these decisions helps with patient questions and survivorship planning.

Stage I seminoma: The preferred approach for most men is active surveillance — ~15% will relapse (always curable at that point), and 85% avoid any further treatment beyond orchidectomy. Risk-adapted adjuvant single-dose carboplatin (AUC 7) is an alternative for men with high-risk pathology or poor surveillance compliance (Oliver et al, MRC TE19, J Clin Oncol 2011; Aparicio et al, SGCCG, J Clin Oncol 2014). Adjuvant radiotherapy is largely no longer standard in Australia because of long-term second-malignancy and cardiovascular risk.

Stage I NSGCT: Surveillance is again preferred in compliant men. One cycle of BEP as adjuvant is an evidence-based alternative for high-risk pathology (lymphovascular invasion, embryonal carcinoma predominance) (Tandstad et al, SWENOTECA, J Clin Oncol 2009).

Stage II–III: Three to four cycles of BEP — bleomycin 30 units weekly, etoposide 100 mg/m² days 1–5, cisplatin 20 mg/m² days 1–5, every 21 days (Einhorn and Donohue, Ann Intern Med 1977). This regimen transformed metastatic GCT from ~10% cure to >70%. Chemotherapy is delivered under Section 100 Efficient Funding of Chemotherapy through a hospital or day-oncology unit.

Bleomycin alert: document bleomycin exposure permanently in the medical record and flag it clearly. High inspired oxygen concentrations during future general anaesthesia can precipitate fatal pulmonary fibrosis in bleomycin-exposed patients — anaesthetists must know.

D. Australian operations

MBS items useful for the GP:

• Standard GP attendances: items 23 / 36 / 44
• Scrotal ultrasound: 55059; CT chest: 56407; CT abdomen/pelvis: 56412
• Tumour markers: β-hCG 66608, AFP 66711, LDH 66660 — repeatable per oncology protocol for surveillance
• Mental Health Care Plan: 2715 / review 2717
• Chronic Disease Management Plan: 65 / review 66 (for survivorship comorbidities)
• GPCCMP for complex care: 965 / review 967 — applicable post-cisplatin with cardiovascular risk, hypogonadism, or psychological comorbidity
• Telehealth video (91790) / phone (91891): ideal for ongoing survivorship reviews; not appropriate for first assessment of a scrotal lump (in-person examination required)

PBS:

• BEP chemotherapy regimen: Section 100 Efficient Funding of Chemotherapy (hospital/day-oncology setting)
• Carboplatin adjuvant stage I seminoma: Authority Required Streamlined, Section 100
• Pembrolizumab for relapsed/refractory GCT: Authority Required Section 100 (limited indication)
• Testosterone replacement for confirmed post-treatment hypogonadism: Authority Required Streamlined (bilateral orchidectomy or both testes affected); longer Authority Required process for unilateral disease

Referral checklist: when sending to urology, include the scrotal ultrasound report (and images if obtainable), the β-hCG / AFP / LDH results, FBC / UEC / LFTs, documented examination findings, risk-factor history (cryptorchidism, family history, prior testicular cancer), fertility-relevant history, and a mental health screen result.

DVA: Testicular cancer is an accepted DVA condition under the Statement of Principles with recognised occupational hazard exposure for some military and firefighting personnel. Gold and White Card cover diagnosis and treatment.

E. Special populations

Men with prior cryptorchidism. Even after successful orchidopexy, the lifetime risk of GCT remains 4–8 times higher than background. The corrected testis should be clinically examined annually and patients encouraged to report any change. Document the history prominently.

Bilateral or synchronous disease. About 1–2% of men have bilateral involvement at presentation. Organ-sparing surgery (partial orchidectomy) is feasible only in highly selected cases at expert centres — typically a solitary testis or synchronous bilateral small masses with normal testosterone.

Adolescents and young men (under 18). Yolk-sac tumour is the dominant histology in prepubertal boys (AFP elevations are physiologically normal in infancy and must be age-adjusted). Management differs from adult protocols — paediatric oncology referral is appropriate. Seminoma is rare before puberty.

Men who are HIV-positive. GCT risk is modestly increased and histology may be atypical. Treatment response is generally similar to HIV-negative men on contemporary antiretroviral therapy; coordinate with an infectious-disease specialist regarding drug interactions during BEP.

First Nations men. Testicular cancer incidence is lower in Aboriginal and Torres Strait Islander men than in men of Northern European ancestry. When it does occur, equity of access to specialist oncology care, fertility services, and survivorship follow-up is essential — the Cancer Council 13 11 20 support line can assist with navigation.

Men planning fatherhood after treatment. Spermatogenesis recovers in approximately 60–80% by two years post-chemotherapy (Brennemann et al, Andrologia 2009). A fertility review at two years is appropriate; for men who remain azoospermic, banked sperm and ICSI are the pathway.

When to escalate

Immediately (same-day emergency referral or hospital transfer):

• Suspected epidural extension from a retroperitoneal mass with back pain and neurological deficit
• Superior vena cava syndrome from mediastinal lymphadenopathy
• Massive haemoptysis from pulmonary metastases
• Any presentation with testicular pain of sudden onset — testicular torsion must be excluded as a surgical emergency alongside cancer (the two can coexist)

Urgently (within 2 weeks — suspected-cancer pathway):

• Any ultrasound-confirmed intratesticular solid mass
• Any firm intratesticular mass found on examination regardless of imaging result
• Elevated AFP or β-hCG in a young man without an alternative explanation
• Persistent unilateral testicular enlargement or change in consistency not resolving within 2–4 weeks

Routine (non-urgent specialist referral):

• Testicular asymmetry or atrophy without a discrete mass — for monitoring and counselling
• Varicocele or hydrocele without an underlying solid mass
• Survivorship co-management referrals (exercise physiology, psychology, dietetics, endocrinology)

What this article is and is not

This is general health information drawn from current Australian general practice sources — Cancer Australia 2024, eviQ, RACGP, ANZUP, Therapeutic Guidelines, Australian Medicines Handbook — and major international trials. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about specific management, including staging workup, adjuvant treatment, and survivorship monitoring, are made between the patient and the treating multidisciplinary team.

For Australian consumer-friendly resources: Cancer Council Australia — Testicular cancer, Healthy Male, Australian Testicular Cancer Trust, HealthDirect — Testicular cancer, Better Health Channel.

For cancer-related emotional support: Cancer Council 13 11 20, Beyond Blue 1300 22 4636, Lifeline 13 11 14.

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Sources cited

1. Cancer Australia — Testicular cancer (2024)
2. AIHW — Cancer data in Australia (2024)
3. Cancer Council Australia — Testicular cancer
4. RACGP Red Book — Cancer screening
5. Therapeutic Guidelines (eTG) — Oncology / Genitourinary
6. Australian Medicines Handbook
7. eviQ — Testicular germ cell tumour management
8. ANZUP Cancer Trials Group — Germ cell tumours
9. EAU Guidelines on Testicular Cancer (2024)
10. AJCC Cancer Staging Manual, 8th edition — Testis
11. USPSTF — Screening for Testicular Cancer (reaffirmed 2024)
12. Einhorn LH, Donohue J — BEP regimen (Ann Intern Med 1977)
13. Oliver RT et al — MRC TE19 carboplatin vs RT stage I seminoma (J Clin Oncol 2011)
14. Aparicio J et al — SGCCG risk-adapted stage I seminoma (J Clin Oncol 2014)
15. Tandstad T et al — SWENOTECA risk-adapted NSGCT (J Clin Oncol 2009)
16. Brennemann W et al — Sperm cryopreservation in testicular cancer (Andrologia 2009)
17. de Sá Earp AP et al — Contralateral testicular biopsy (Andrology 2019)
18. Demark-Wahnefried W et al — CARE Trial (J Clin Oncol 2008)
19. Healthy Male — Testicular cancer
20. Australian Testicular Cancer Trust
21. HealthDirect — Testicular cancer
22. Better Health Channel — Testicular self-examination