A Urologist's Perspective on Testicular Cancer Treatments

Board-certified urologist Dr. Jason B. Carter explains his role in the diagnosis of testicular cancer.

"It's important to understand that when you have a diagnosis like testicular cancer, to some degree, the urologist may be the quarterback in the beginning. With testicular cancer, the urologist is going to be the one you meet, get the initial procedures done, and do the post-op follow-up.

"I'm very fortunate to have an excellent radiation oncologist that I work with, and very fortunate to have a couple of very, very good medical oncologists that I work with.

"Definitely anytime you have any kind of cancer, including testicular cancer, it is always a team approach." 

He shares his insights on treating testicular patients at Unity Urology, his practice in East Tennessee. He has been providing quality urologic care since 2003 and opened Unity Urology in 2006 in Greenville, Tennessee. 

Other urologic conditions to know about: Dr. Carter talks about other urologic conditions such as low testosterone, other hormone therapies for men and women, infertility, incontinence, and erectile disfunction. He is a medical advisor for Aeroflow Urology.

Dr. Carter's medical degree is from East Tennessee University. He completed a residency at the University Hospital and clinics in Columbia, Missouri. He is board-certified in urology by the American Board of Urology and a member of the American Urological Association and the Tennessee Medical Association. 

Transcript

A Urologist's Perspective on Testicular Cancer Treatments 

Introduction 

[00:00:00] Welcome to Don't Give Up On Testicular Cancer, a podcast where testicular cancer survivors, caregivers, and others who have navigated the cancer journey share their stories. 

The podcast comes to you from the Max Mallory Foundation, a non-profit family foundation focused on educating about testicular cancer in honor and in memory of Max Mallory, who died in 2016, at the young age of 22, from testicular cancer. Had he survived, Max wanted to help young adults with cancer. 

This podcast helps meet that goal. Here now is your host, Joyce Lofstrom, Max's mom, and a young adult cancer survivor. 

Joyce Lofstrom: With me [00:01:00] today is Dr. Jason B. Carter. He's a urologist, and he's been providing his outstanding care since 2003. His medical degree is from East Tennessee University, and he completed a residency at the University Hospital and clinics in Columbia, Missouri, which we've already discussed as my alma mater.I always like to mention that. 

He opened his private practice in Greenville, Tennessee, in 2006. He is a board-certified urologist by the American Board of Urology and a member of the American Urological Association and the Tennessee Medical Association. So welcome, Dr. Carter. Thanks so much for being here.

Dr. Jason B. Carter

It's a pleasure. 

Joyce Lofstrom

So, why don't you start by telling us a little bit about your practice and your career as a urologist? Then, we can discuss testicular cancer in more detail. 

Dr. Jason B. Carter

Well, I'm originally from Tennessee. I went to the University of Tennessee, Knoxville, for [00:02:00] college. I went to East Tennessee State University for medical school, so both were in the East Tennessee area. I then branched out to Missouri and the University of Missouri, Columbia, for my residency.

And you know, I decided to go into general urology practice. My wife supported me through medical school and residency, and when I mentioned doing a fellowship, she said, "It's time for you to get a job." So, my first job was in Greenwood, South Carolina. I was there for three years, then we moved back home to East Tennessee, and we've been in Greenville, Tennessee, a small town in East Tennessee, for the last 20 years. 

So I've been in private practice for 23 years. Practice general urology. Unfortunately, what we're seeing in the urology field is really an impending shortage of urologists, especially in rural areas. So I think my area would be categorized as [00:03:00] rural. 

For instance, in my town, in my county, I'm the only urologist, which affords me an opportunity to see a lot of patients as a general urologist. I have my hand in a lot of diverse urologic problems and conditions, treat those with assistance from my oncology colleagues, and then refer to tertiary care centers when we need to do that. Fortunately, in Knoxville, we have a large university hospital that we can ask for assistance, and we have Vanderbilt in Nashville, which is an excellent institution. 

When you need that highly specialized care, we can get our patients down to one of those two institutions. 

Joyce Lofstrom 

I think that's good to know for listeners who might be in your area, because I know a lot of times people don't know where to go for care for just a urology issue, but then testicular cancer, so it sounds like you have great options for care for [00:04:00] anyone that might need that for testicular or any situation. 

Dr. Jason B. Carter

Living in a rural area, we're probably socioeconomically limited. My patients can be limited with transportation, finances, and stability to take time off from work. And I think a good place to start, especially with something like a testicular lump or lesion, is just your local general urologist.

We can do a lot of the initial workup. An initial procedure can become something specialized. I always tell my patients, "Let's get you to a higher facility to get some specialized care, but come back to me and let me do the routine follow-up." It saves patients a lot of time driving, and that kind of thing. We always tell our patients, "Go get what you need to get done if we don't offer that, but always come back." And let us help as much as we can. [00:05:00] 

Joyce Lofstrom 

That's good advice. I think for all of us. Can you talk a little bit about what you've seen over the years with testicular cancer patients? 

One question I have for you, and that I've heard from some of the men I've talked to, is how they often don't know how often to check for a lump, and then they see it and are surprised. That's a good piece of advice that's important to understand. 

Dr. Jason B. Carter

Of course, it's very important. I think that women probably do a much better job of educating themselves about what they should be doing for their health. In some ways, women's health is probably addressed much better than men's health.

Women get pelvic exams, pap smears, and mammograms very early, so they get introduced into the system quite early. You know, a lot of times, the first time a male patient is going to see a doctor would typically be [00:06:00], maybe when they're 30 or 40 years old, and their wife convinces them that it's time to go get a checkup.

Joyce Lofstrom

Yeah, I know, I know. 

Dr. Jason B. Carter

And you know, I'm a little bit different. I mean, of course, being in the medical field, you know, I was given a lot of knowledge early on in my life, and I'm not sure that we really tell men that they should be doing. A male breast exam, male breast cancer is pretty rare, but they should also be doing a testicular self-exam.

Dr. Jason B. Carter

And you know, really, the primary age group for testicular cancer is young men. Usually, I will tell a patient that men aged 20 to 40 years old are the primary age group, and all those men, at least monthly, should be doing a testicular self-exam. And I'm not sure that we tell men like that, like we're supposed to.

It's probably not mentioned by the doctors, and then, within families, a lot of times those types of issues aren't really talked about or addressed. [00:07:00] So, you know, a lot of times if a man comes in. Especially if they have felt a little something that worries them in the testicular or scrotal area.

It might be the first time they're seeing a doctor. 

Joyce Lofstrom

Yes, I know that's very true. I just think what you said about knowing how to do the exam is important. Being able to say that to a man and make sure you do this every month, that type of thing. And the more doctors like you can help us with that, hopefully, it'll change. 

Dr. Jason B. Carter

There are good and bad things about the internet. I always encourage my patients to do some self-education if that comes up. I don't think all the information is bad. You can certainly sometimes go down a rabbit hole and get more confused than educated, but I think that is one nice thing about the internet

Before, if a man felt a lump or [00:08:00] something on the testicle, a lot of times there's embarrassment. There may be anxiety, fear, and sometimes people's reaction is to ignore the problem. But, I think a lot of men now go on and Google, hey, a lump on the testicle, and they can read a little bit about that, maybe feel a little bit more comfortable or confident about seeking out an exam, and maybe not be quite as anxious or quite as likely to ignore that.

It's just a thought. You know, before the internet age, you were just kind of a person who felt something, but at least now, men have a resource that they can go to and at least get the ball rolling on getting a problem checked out in that regard. 

Joyce Lofstrom

Yeah, I think you're right. And I also think, when I think about it, when I look for health information for myself, I try to think about the source of, you know, who's saying this about whatever it is I'm looking up. It's a medical professional who's giving the advice versus someone I don't know. So I think that's [00:09:00] important. 

But I want to know what advice you have for patients beyond testicular cancer who are under a urologist's care. When do you go see a urologist? If you're a guy, do you just consider that an annual visit you should have as one of the specialists in your care? Or any thoughts on that?

Dr. Jason B. Carter

One problem with healthcare is that it has become so fragmented. There's a specialist for everything.

You can say doctors, most of the time, see sick people. Maybe the healthy people don't go to the doctor as much, but I think a lot of our family physicians can be quite overwhelmed by how unhealthy the patients are that they're seeing.

Dr. Jason B. Carter

You know, between obesity, metabolic syndrome, diabetes, high blood pressure, and all those sorts of things, you would hope that the primary care provider can address questions that might come up about [00:10:00] low testosterone, erectile dysfunction, and urinary problems. 

But a lot of times, I think they're busy, quite frankly, maybe overwhelmed, and don't have the time or the knowledge base because knowledge in all medical fields is advancing so rapidly. It can be difficult for me sometimes with what's going on. So in one regard, hopefully, if you're having an issue, your primary care provider might be a good place to start.

Quite honestly, I also have a huge interest in hormonal therapy. I'm only one person, so I can only see so many patients, but I would really encourage any male or female who is having a hormonal-related issue, a urinary issue, an erection issue, or a fertility issue.

There's nothing wrong with seeking out a urologist as the first person that you see to address those issues. A lot of times, that's what we're [00:11:00] focused on, what we're going to talk about, and we have the knowledge. 

I've never required referrals to come to my practice. I've always allowed people to make their own appointment and come in. We're seeing younger and younger patients for a variety of issues. Low T, infertility, erectile dysfunction, but a lot of that speaks to just, I think, how generally unhealthy we are. And when I say unhealthy, that includes stress, poor sleep hygiene, poor diet, and a lot of these things contribute to issues that will affect people, and a urologist can address. 

So, I would encourage patients who have any kind of issue to seek out a urologist very early on. Maybe that urologist will have an interest in hormones.

Not many people have a huge interest in that medical field. You really have to seek out a hormone-type clinic. But I've tried to incorporate that into my medical practice because I see a huge need for it. And then [00:12:00], especially for testicular cancer patients, once they go through treatment, that is something that definitely needs to be addressed very early on because it can have a huge impact on how patients feel and how they perform. 

Joyce Lofstrom

That's good to know. We haven't talked a lot about the hormonal side of it on the podcast, and I know it's important. Some men I've talked to have lost both testicles, so they really need to focus on the hormones.

I also wanted to talk. You mentioned some of the other side effects of testicular cancer. I'd like you to tell us about your work with Aeroflow and how that helps testicular cancer patients.

Dr. Jason B. Carter

With the treatment of testicular cancer patients, it should not really lead to urinary issues, right, especially in the early stage. Now, when you have later-stage patients who may need chemotherapy, who may [00:13:00] need radiation therapy, and certainly patients who may need a procedure called a retroperitoneal lymph node dissection. 

That involves trying to clean out lymph nodes that can be intimately involved with the nervous system. Those are patients who tend to have some degree of urinary dysfunction or urinary side effects. And it can be, you know, things like frequency, urgency of urination, loss of control, not only sort of urge incontinence, but also stress incontinence. And then, rarely, a condition called detrusor sphincter dyssynergia, where the bladder and the urinary sphincter aren't communicating properly. 

So some of those can be nerve side effects with the RPLND procedure. Some can be sort of neuropathy created with the chemotherapy, the fibrosis of the bladder, [00:14:00] or irritation of the bladder from the radiation. Some of the chemotherapy- and radiation-related side effects can be met more short-term and may be managed with physical therapy or a simple medication. But, if patients have an injury to the nervous system, the sympathetic nervous system, with a lymph node dissection, those things can take a little bit longer to resolve and require a little bit more effort, working with the patients and trying to get them better.

Joyce Lofstrom

Wow, that's a lot. But it's, it's good to understand it. Can you tell us a, what the side effects are, and then b, like you said, some of it is short-term, and then others could be more involved depending on the kind of treatment that you've had. So, just the physical therapy component of it.

Dr. Jason B. Carter

A lot of times, that's an additional [00:15:00] expense for the patient. It can be transportation, you know, time off work, right? I really encourage a lot of my patients to think about physical therapy and have a non-medical route to getting better. Because, you know, sometimes it's really easy to put patients on medications, and you can have side effects with those as well.

Physical therapy is very important. Also, newer medications have fewer side effects than some of the older ones. There are many medical options, and there are procedural-based options for incontinence. 

And then of course, if you need temporary help with guards, pads, briefs, that type of thing, Aeroflow is really great to work with. We work with them pretty much exclusively in my office for our catheter supplies and incontinence supplies, and really have never had an issue. They've been a great company and a [00:16:00] great team to work with, and they make my job a lot easier because we just have a little iPad, and we put in what we need, and the patients get what they need, and it's a, it's a really smooth process.

Joyce Lofstrom

Well, that's good to know because patients don't know where to go if they need those kinds of supplies. It's like, do I just go into the grocery store and buy them? Or, or what? And the more specialized products and designs, like you're describing, that's a really important piece that sometimes gets lost in the discussion.

So I thank you for sharing that, because I think it's important. 

As you think about what's ahead with testicular cancer, what advice might you give to some of your patients or young men listening to help them either stay on top of it, if you find something? Or, any guidance that you might have for our listeners?

Dr. Jason B. Carter

I want to say [00:17:00] certainly, being a more rural general urologist, right, testicular cancer in a typical urology practice is not an overly common thing, right?  And I would say number one, like every man should be doing a testicular self-exam once a month.

Even if you feel like your testicles are, maybe you don't feel a lump or a bump if they're on the small side, right? That might be a reason to come in to discuss fertility and testosterone-related issues. Testicles may not be functioning optimally. Certainly, if you feel a lump, a bump, a nodule, or something down there, we certainly want you to come in and get that checked.

But fortunately, most of the time when men come in, it is not a testicular cancer. It might be a fluid collection around the testicle called a hydrocele. It could be a cyst on the [00:18:00] testicle or the epididymis, you know, an epidermal cyst, a spermatic seal. It could be a little calcification around the testicle called a scrotal pearl.

Most of them are very common, benign findings, and a simple exam will oftentimes really say, "Hey, listen, this is not cancer. This is kind of normal." You also get a chance to explain the anatomy of the testicle to the patient, which a lot of people don't really understand.

We keep charts and diagrams in the exam rooms. But certainly, I think a lot of men may ignore those things. Maybe it's anxiety, maybe it's fear, maybe it's a lack of insurance. Even for patients who have insurance, a huge issue is the copays, the deductibles, and the out-of-pocket expenses, which are getting higher and higher every year.

And you may say, see a relatively young person who has a 7, 8, 9, $10,000 deductible [00:19:00], and just to come to the doctor's office is essentially they're paying for that full visit in cash. You know, I certainly always encourage patients. You really have to put the financial part aside and make sure you take care of yourself and your health, because certainly if you are one of those patients who come in, you do have a worrisome lesion or nodule, and we confirm with ultrasound that it is suspicious for testicular cancer.

If we can just do the procedure, remove the testicle, do the orchiectomy. A lot of times, that's all you need, right? You know, part of that workup, we do an exam, we confirm with ultrasound, we get appropriate tumor markers, we do a CT, and make sure we stage the patient accurately.

And you know, I saw a patient the other day who had a really large, abnormal testis. We did the tumor markers, and he had put that off for a while. He has no insurance, but you know, even in cases where you're worried that this could be more advanced, he had a seminoma, which is a [00:20:00] favorable pathology.

It was stage one, and it was confined. We did his procedure, and we'll just have him on an active surveillance protocol. So, you know, it's just so unfortunate when men put those things off. Because if we catch it early in stage one, we do the procedure, and for the vast majority of patients at that stage, that's all they are ever going to need.

Of course, we follow up postoperatively for months and several years after. I would just encourage patients to come in and get it (the exam). We try to make the patients feel very comfortable. We try to teach them the anatomy, answer all their questions, and reassure them. 

Dr. Jason B. Carter

But then, if we are worried, we get the appropriate workup done, get them taken care of, and that can take care of it. I would encourage any patient who feels anything down there to just come in and see a urologist. It's a really easy visit for me because a lot of times, I just reassure people, and everybody's happy. If we catch it early, we can get it fixed, and patients do well.[00:21:00] 

Joyce Lofstrom

You're right. The point of catching it early is so important because it does make a huge difference. And like you said, often that's all you do: take care of it, remove it, and manage it with surveillance. And if something else happens, well, you deal with it then, but at least you've got that first step.

Great advice. Is there anything you want to mention that I probably didn't bring up, or you want to share about your work? 

Dr. Jason B. Carter

I would say that one thing I have a real interest in is male and female hormone therapy.

We have a large testosterone replacement therapy component in our practice, and I try to encourage as many women as we can to consider hormone replacement therapy when appropriate, but especially for testicular cancer patients. Not only when patients come in for the initial consultation, if we are more concerned, or a lot of times, patients may come in with an ultrasound with a [00:22:00] true abnormal finding.

One part of my workup, in addition to tumor markers, is also total and free testosterone. We want patients to know where their testosterone levels are preoperatively. If we do an orchiectomy, they are going to lose a testicle. Now, again, with one testicle, especially younger patients, they have very high fertility rates.

Most of the time, they do not have clinically significant low testosterone when they're young. They can still farther children, but we like to have a baseline. Post-orchiectomy, we'll check testosterone, compare our pre- and post-op numbers, and just have that as a reference guide.

At that point, if the patient is not symptomatic, we encourage them, "Hey, maybe your numbers are in the lower end of the range, but if you have a healthy libido, good erections, and a good energy level, you know, there's no reason to start [00:23:00] therapy.

But when patients do mention, "Hey, I've, I seem to have more brain fog. I don't have as much energy. I'm not as interested in sex. My erections may not be quite as good. Maybe I'm gaining some belly fat that I didn't have before…" then we can always look back at those numbers and, and treat them, when they're clinically symptomatic. We feel like that's important.

When you think about the testicular cancer patient, a lot of times we think about the diagnosis, the treatment, and then the surveillance. But we need to make sure that we address hormonal issues. We need to ask, "Hey, how are you? How's your flow?" 

We want to make sure there are no issues there. How are you feeling about your diagnosis? For a lot of patients with any type of cancer, you see the doctor, you get your scan results, and everything looks good. We'll see you in six months. And then for five months, you're okay. And then that month leading up to it, a lot of anxiety kind of [00:24:00] worry is my scan going to look good?

Dr. Jason B. Carter

So, just making sure that they feel comfortable with how things are going, and you address any anxiety or concerns that they have, and discuss fertility, just a lot of issues. But I think, just making sure that you address the hormonal component of it.

Make sure you address the urinary function or control portion of it, but then also the fertility portion of it. Certainly, for our young men who have not had children, making sure that we mention cryo-preserving sperm preoperatively so that they have a chance to father children naturally is very important.

And then also, addressing fertility concerns that they might have postoperatively. 

Joyce Lofstrom 

Okay. That's wonderful. That's a lot of detail and great advice for men to know, so I appreciate that. You may have to come back and talk some more about some of these different items. 

So, my last, what? Go ahead. 

Dr. Jason B. Carter

I think it's important to understand that [00:25:00] when you have a diagnosis like testicular cancer, to some degree, the urologist may be the quarterback in the beginning. You know, of course. I'm very fortunate to have an excellent radiation oncologist that I work with, and very fortunate to have a couple of very, very good medical oncologists that I work with.

So, you know, it's definitely anytime you have any kind of cancer, including testicular cancer, it is always a team approach. And I think testicular cancer is one where the urologist is going to be the one you meet, get the initial procedures done, and do the post-op follow-up. You may be meeting a radiation oncologist, so every urologist needs a good one of those.

You may need a medical oncologist. Every urologist needs a good one of those. I'm fortunate, even though I'm in a small town, that we have an excellent oncology team. I feel very confident when I need assistance from those [00:26:00] doctors that my patients are getting very good care.

Joyce Lofstrom

That's great. Yeah. So my last question is, what song, when you hear it, do you have to sing along? 

Dr. Jason B. Carter

Well, you know, I saw that question, and I would probably have to say any Morgan Wallen song. 

Joyce Lofstrom

I don't know. Morgan, tell me about Morgan Wallen. I don't know him or her. 

Dr. Jason B. Carter

He's country music, and I like him and enjoy his music. He's a singer-songwriter. I think he writes a lot of his own music. He's from East Tennessee, so, you know, in his songs he talks a lot about Tennessee and football and growing up in East Tennessee. I think sometimes you just find artists that you like and kind of speak to you.

Dr. Jason B. Carter

So, anytime Morgan Wallen is on, I'm singing, and my wife and daughter are rolling their eyes. I promise you, I cannot carry a tune. 

Joyce Lofstrom

Oh, I'm with you [00:27:00] on that. My fourth-grade teacher told me to fake it when I was singing, so it was so bad. It's true, but that's a longer story. But anyway. Well, I really appreciate your time, and I hope you'll come back and tell us more.

Dr. Jason B. Carter

Oh, yeah. Anytime, you know, just send me an invitation. I'm glad to talk to you. 

Joyce Lofstrom

Okay. All right. Well, thank you. Bye-bye.

Closing

Thank you for watching this episode of Don't Give Up on Testicular Cancer. If you enjoyed this podcast, please subscribe to our program on your favorite podcast directory. You can also visit the Max Mallory Foundation at www.maxmalloryfoundation.com/podcast to listen to previous podcast episodes or donate to the foundation. Join us again next time for another episode of Don't Give Up on Testicular Cancer.