An Interview With Savio P. Clemente
Educate yourself about your cancer. Talk to and read stories of previous patients who have gone through successful treatments with testicular cancer. Many celebrities have shared their experiences on social media and inspired many other patients. One example is Lance Armstrong, an American road racing cyclist who was diagnosed with stage III testicular cancer when he was 25. He underwent treatment successfully and went back to competitive cycling. Famous Indian cricketer, Yuvraj Singh, was diagnosed with testicular cancer and underwent treatment. He went back to international cricket after successful treatment.
Cancer is a horrible and terrifying disease. There is so much great information out there, but sometimes it is very difficult to filter out the noise. What causes cancer? Can it be prevented? How do you detect it? What are the odds of survival today? What are the different forms of cancer? What are the best treatments? And what is the best way to support someone impacted by cancer?
In this interview series called, “5 Things Everyone Needs To Know About Cancer” we are talking to experts about cancer such as oncologists, researchers, and medical directors to address these questions. As a part of this interview series, I had the pleasure of interviewing Shamudheen M. Rafiyath.
Shamudheen M. Rafiyath, MD earned his medical degree from Trivandrum Medical College in India before completing his internship in internal medicine at Long Island Jewish Forest Hills Hospital in Queens, NY. Dr. Rafiyath went on to complete his fellowship in hematology and oncology at New York Medical College at Westchester Medical Center in Valhalla, NY and his internal medicine residency at the Overlook Medical Center in Summit, NJ. He is board certified in medical oncology and hematology. Dr. Rafiyath specializes in breast, lung, skin, and head and neck as well as gastrointestinal cancer, genitourinary cancer, and blood malignanices. He is part of several professional affiliations, including the American Society of Clinical Oncology and the American Society of Hematology. He is fluent in English, Malayalam, and familiar with Hindi and Tamil.
Thank you so much for joining us in this interview series! Before we dive into the main focus of our interview, our readers would love to “get to know you” a bit better. Can you tell us a bit about your childhood backstory?
Iwas born into an agricultural family in a rural village called Nedumangad in the southern state of India, Kerala. My father was a ‘traditional setter’ and one of the skills he learned from his ancestors was to treat minor injuries, bites, sprains, contusions, etc. I grew up watching him treat his friends and family with various kinds of traditional oils and techniques. Despite not having any formal medical education, he was able to receive a lot of confidence and trust from his patients. This instilled in me an interest in medicine at a very young age. I was able to complete my medical degree in India and my desire for advanced learning took me to the United States to complete my Internal Medicine Residency and fellowship in Hematology and Oncology.
What or who inspired you to pursue your career? We would love to hear the story.
During the second year of my internal medicine residency, there were some mandatory electives that we rotated in the specialty department and I chose to do my electives in hematology and oncology. It was during that rotation I was sent to pathologist, Dr. Magidson, to learn more about pathology. Dr. Magidson was a very interesting pathologist and he pointed to the microscope behind his chair. He told me that now the microscope is behind his chair, but it used to be in front of his chair on the table. The reason he provided me opened my mind to the fascinating world of oncology. He said looking under the microscope has become less important and these days we use more advanced technologies to make the diagnosis using flow cytometry, molecular studies, etc. Dr. Magidson told me about Chronic Myelogenous Leukemia (CML) and the pathology behind the condition. CML is associated with the formation of a unique gene product called the Philadelphia chromosome (BCR-ABL1). This de-regulated chromosome is the driver of the disease and has become a primary target for the treatment of this disorder. The invention of the targeted agent Imatinib has changed the life of many patients who are suffering from CML. His explanation of how this therapy has taken a significant amount of patients out of terminal-stage illness and back to normal life was inspirational and motivating. It was that day I chose my specialty and decided to pursue hematology and oncology.
This is not easy work. What is your primary motivation and drive behind the work that you do?
Oncology is a specialty that thrives on having a particularly strong doctor-patient relationship. I have had the opportunity to know patients and their families in-depth and have had the privilege to help them through extremely difficult times. It is a dynamic specialty with rapid evolvement and technological advances like diagnostic tests, rapid drug developments and new modality therapies which change the course of the disease and quality of life.
What are some of the most interesting or exciting projects you are working on now? How do you think that might help people?
At Arizona Oncology, we work as a team to improve patient outcomes. We hold weekly Tumor Board meetings which give us the opportunity for a multidisciplinary discussion of cases with the incorporation of different specialties including surgery, pathology, radiation oncology, radiology and other necessary subspecialists. This enables us to develop a comprehensive plan for our patients. We also have a specified research team and as a member of the US Oncology Network, our patients have access to the most advanced clinical trials.
For the benefit of our readers, can you briefly let us know why you are an authority on the topic of Testicular Cancer?
After completing my medical degree in India, I decided to move to the United States to complete my higher studies. I completed 3 years of internal medicine residency in 2009. I continued my specialty training by joining the fellowship in hematology and oncology and graduated in 2012. I started practicing as an oncologist in 2012 and in my past 10 years of practice, I have treated a large number of patients with cancer. I have a special interest in breast cancer and genitourinary cancers, including testicular cancer and blood malignancies.
Ok, thank you for all of that. Let’s now shift to the main focus of our interview. Let’s start with some basic definitions so that we are all on the same page.
What exactly is testicular cancer?
Testicular cancer is cancer that forms in tissues of 1 or both testicles. Testicular cancer is one of the less common cancers (1%) but the most common cancer affecting young men between the ages of 15 and 35.
What causes it?
The most important risk factor for developing testicular cancer is undescended testis or cryptorchidism. Another risk factor is “Klinefelter syndrome” where a male inherits more than 1 X chromosome which causes undeveloped testicles. A personal and/or family history of testicular cancer also increases the risk of testicular cancer. Caucasians have an increased incidence of testicular cancer as well.
What is the difference between the different forms (if any) of testicular cancer?
The most common type of testicular cancer is a germ cell tumor. There are 2 main types of germ cell tumors: Seminomas and non-seminomatous (NSGCT).
Seminomas are more likely to present with localized disease. Approximately 80% of males with a seminoma present with a stage I disease (limited to the testicle). Seminomas tend to grow and spread more slowly than NSGCT and have a good prognosis. Seminomas are the most curable solid tumors and are treated with surgery and in advanced stages, by surgery, chemotherapy and radiation in special circumstances.
Non-seminomatous germ cell tumors (NSGCT) are variable in appearance and prognosis. There are 4 main types of NSGCT:
Embryonal carcinoma: Present in about 40% of tumors. Rapidly growing and potentially aggressive. Can secrete beta-hCG and alpha-fetoprotein.
Yolk sac carcinoma: The most common type of tumor in children. Secretes alpha-fetoprotein.
Choriocarcinoma: A rare but very aggressive form of testicular cancer that can secrete beta-hCG.
Teratoma: Most often appears as a myxoid NSGCT; usually grows locally but can appear in retroperitoneal lymph nodes. Teratoma is chemotherapy and radiation-resistant and best treated with surgical removal.
The treatment of NSGCT is based on surgical staging, tumor markers and risk factors including lymph vascular invasion and histology. For early-stage low-risk disease, active surveillance or chemotherapy is an option after radical orchiectomy. Patients with early-stage high-risk disease for persistent elevation of tumor markers postoperatively are usually treated with retroperitoneal lymph node dissection or chemotherapy or both. For advanced age disease, chemotherapy followed by evaluation for residual disease is the main form of treatment.
These tumors are rare and develop from the supportive tissue around the gem cells and the testicle. These tumors have an excellent prognosis if surgically removed.
There are 2 types of stromal tumors:
Leydig cell tumor: Leydig cells make the male hormone testosterone and are often cured with surgery.
Sertoli cell tumors: Sertoli cells support and nourish the developing sperm and are usually benign tumors.
I know that the next few questions are huge topics, but we’d love to hear your thoughts regardless. How can testicular cancer be prevented?
There is no effective way to prevent testicular cancer. In children with undescended testis, surgical repositioning of the testis (Orchiopexy) before puberty appears to decrease the risk of testicular cancer but does not eliminate it. A healthy lifestyle, avoidance of alcohol, avoidance of smoking and exercise will play an improved role in the outcome of testicular cancer treatment.
How can one detect the main forms of testicular cancer?
Most men feel this as a hard lump in the testicle, usually painless. If you feel a lump in the testicle or a dull ache or heavy sensation in the lower abdomen, perianal area or scrotum then you should seek attention from your doctor.
Detection of early-stage or late-stage cancer starts with a detailed history and physical examination.
The manifestations of advanced-stage testicular cancer include neck mass, cough, dyspnea, anorexia, nausea, vomiting, lumbar back pain, bone pain, central or peripheral nervous system symptoms and unilateral or bilateral lower extremity swelling.
A bimanual examination of the scrotal contents, starting with normal and contralateral testis, to appreciate the relative size and consistency of normal testes as a baseline for comparison.
Physical examination should also include palpation of the abdomen for evidence of nodal disease or visceral involvement. Routine assessment of the supraclavicular lymph node may reveal adenopathy in men with advanced disease. Examination of the chest may disclose gynecomastia or suspicion of thoracic involvement.
The diagnostic evaluation of men with suspected testicular cancer includes scrotal ultrasound followed by radiographic testing and measurement of serum tumor markers. Testicular biopsy is not performed as a part of the evaluation due to concern that it may result in tumor seeding into the scrotal sac or metastatic spread of the tumor into the inguinal nodes.
If you find a testicular tumor, you will likely undergo a procedure called radical inguinal orchiectomy for the removal of the testicle with the tumor. This will allow for histologic evaluation of the primary tumor and provide local control. The evaluation of the tumor will help to determine the type of testicular cancer to help plan the most effective treatment.
Cancer used to almost be a death sentence, but it seems that it has changed today. What are the odds of surviving testicular cancer today?
Testicular cancer has become one of the most curable solid neoplasms. The 5-year survival rate is nearly 95%.
Can you share some of the new cutting-edge treatments for cancer that have recently emerged? What new cancer treatment innovations are you most excited to see come to fruition in the near future?
Comprehensive molecular profiling can analyze the genomic biomarkers and reveal the personalized molecular profile to select the most appropriate cancer therapy including targeted treatments, appropriate chemotherapy, and immunotherapy.
Immunotherapy has changed the outcome of cancer treatment significantly in recent years. Immunotherapy strengthens the body’s defense against cancer which provides a greater chance of achieving treatment success. Advance immunotherapy treatment options, with targeted immunotherapy invoking a multidimensional attack on cancer cells and elimination of cancer resistance is the future of oncology therapy.
Healing usually takes place between doctor visits. What have you found to be most beneficial to assist a patient to heal?
Many factors can assist in healing cancer patients. The most beneficial factor is to build up a patient’s motivation. Motivation can be built by becoming educated about the disease, being involved in shared decision making, building trust in physicians and treatment, drawing inspiration from other patients’ experiences and of course, empathy from physicians, staff, etc.
From your experience, what are a few of the best ways to support a loved one, friend, or colleague who is impacted by cancer?
Be with your loved ones, educate yourself about cancer, support your loved ones’ treatment decisions, learn about their needs and assist them in whatever way possible.
What are a few of the biggest misconceptions and myths out there about fighting testicular cancer that you would like to dispel?
Some of the misconceptions and myths about testicular cancer are:
1. After radical orchiectomy, you cannot have kids. This is wrong. After radical orchiectomy, the other side of the testicle will continue to produce sperm and you can still have kids.
2. There is a misconception that after the testicle is removed testosterone levels go down and decrease sexual activity. The testosterone levels will go back to normal levels in a few days to a week after removal of the testicle and sexual drive and libido will typically function normally after removal of the testicle.
3. The diagnosis of testicular cancer is not a death sentence. Testicular cancer at any stage is not a death sentence and is the most curable solid tumor, cured almost 95% of the time. This is the most curable cancer even with relapse or recurrence.
Thank you so much for all of that. Here is the main question of our interview. Based on your experiences and knowledge, what are your “5 Things Everyone Needs To Know About Testicular Cancer? Please share a story or example for each.
1. Testicular cancer is a young man’s cancer between the ages of 15 and 35.
2. It most commonly presents as a testicular painless hard mass. From my patient experience, the majority of patients detect the mass by themselves. A testicular self-exam is a very effective way to notice any lumps, nodules or changes at the testicle. If you notice any change in your testicle, seek medical attention immediately. Earlier is better for any cancer diagnosis.
3. The main part of treatment is the surgical removal of the affected testicle. Removal of the single testicle is less likely to affect your sexual activity and testosterone levels and you can still have children after one is removed.
4. Treatment is highly curable (up to 99%) at the early stage and up to 93% with advanced age.
5. Educate yourself about your cancer. Talk to and read stories of previous patients who have gone through successful treatments with testicular cancer. Many celebrities have shared their experiences on social media and inspired many other patients. One example is Lance Armstrong, an American road racing cyclist who was diagnosed with stage III testicular cancer when he was 25. He underwent treatment successfully and went back to competitive cycling. Famous Indian cricketer, Yuvraj Singh, was diagnosed with testicular cancer and underwent treatment. He went back to international cricket after successful treatment.
You are a person of great influence. If you could start a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. 😊
The main strategy for cancer prevention and early detection in the United States is the widespread practice of screening. The cure starts with prevention. The field of oncology has advanced substantially in precision medicine initiated using diagnosis and therapy. However, precision prevention is not advanced currently. The future of cancer prevention and early detection should emphasize the incorporation of precision cancer prevention integration, utilizing our molecular knowledge where screening and cancer prevention regimens can be matched to one’s risk of cancer due to known genomic and environmental factors.
How can our readers further follow your work online?
Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.