Alicia Morgans: Hi, this is Alicia Morgans, Associate Professor of Medicine and GU medical oncologist at Northwestern University. I am so pleased to have here with me today Mike Craycraft, who is a pharmacist as well as being a survivor and founder of the Testicular Cancer Society, that's testicularcancersociety.org. Thank you so much for coming to speak with me today during April, testicular cancer awareness month.

Mike Craycraft: It's my pleasure. Thanks for having me.

Alicia Morgans: Wonderful. So, I wanted to talk with you of course about testicular cancer, but also to think with you a little bit about how the current pandemic and COVID-19 are playing into testicular cancer and patients' willingness, I think, to come forward about this disease, which can actually be tough to come forward about in the first place. So, can you talk a little bit about the importance of testicular cancer awareness and why we should think about this, and then we'll get onto the COVID discussion as well?

Mike Craycraft: Certainly. Yeah, so, you know, as you mention with testicular cancer, guys are very hesitant to mention that they noticed any problems with their testicles or to seek care in a timely manner, and it really kind of puts us behind because, you know, if we're not able to identify guys with early-stage disease, the treatment burdens are much higher. We actually for several years did a survey and asked them, you know, we asked guys who had spoken to them about testicular cancer, and unfortunately, the vast majority said no one. Really, being able to have the guys aware that testicular cancer can happen, it happens at a younger age, and that they just need to seek care quickly is of great importance, just so we're starting off on the right foot.

Alicia Morgans: So, how do you counsel men, and this should be men of any age after puberty really, to think about self-exams? They're not necessarily always encouraged in routine doctor visits because there are so many things to cover, but I think it is something that is of importance for men to think about doing while they're whether in the shower, getting ready for their day, so that they can identify something if something does seem to be amiss.

Mike Craycraft: Yeah, so we recommend that guys do a testicular self-examination once a month. You know, we realize that there are no randomized controlled trials nor will there ever be, because the size would just be too vast to be able to show anything. But, just being familiar with one's body is important, and since most guys or their partners find it themselves it just makes sense. There is data out there showing the larger the palpable tumor, the higher risk it is for stage three disease and the higher risk it is for mortality. So, while there isn't any direct evidence, it makes sense that if you feel the tumor is two centimeters versus six centimeters, you're going to have a better prognosis.

Alicia Morgans: I completely agree, and so these self-exams happening once a month where patients actually feel what's going on down in their testicles, if they feel an abnormality, and to be very clear, it doesn't need to be a painful abnormality. Usually, these testicular masses are painless in most cases. The smaller it is when you feel it, identify it, and have that assessed, the lower the likelihood that cancer has of being able to spread up into the body, spread elsewhere, and then require more treatment and have a higher risk of potentially being a fatal cancer. So, finding these early, and you or your partner are probably the only people that can do that, finding it early is really going to be the most important piece of this. Certainly, engaging doctors when you have an abnormality is going to be really, really critical.

And Mike, how are you thinking about this in the setting of COVID-19 where people are actually encouraged to stay away from the medical community if at all possible if they're not sick, because there is the risk that they could be exposed to COVID-19 if they are a healthy person, or certainly if they come in and they're asymptomatic or minimally symptomatic, they could give COVID-19 to others in the waiting room? What should they do if they find a testicular mass now?

Mike Craycraft: Yeah, and this is a difficult population, too. You know, with it being a cancer that affects young guys, many guys don't even have health insurance when they're contacting us and typically they may have to utilize the ER. We're really trying to encourage them to, you know, one, if they have a physician to contact them first before doing anything, and seeing if it's possible just to schedule an outpatient ultrasound at an imaging center where they can reduce the risk of exposure for both of them and the healthcare professionals.

Alicia Morgans: I agree with that, and just to emphasize that many, many physicians are actually converting their visits to telehealth. And so, if you do find something abnormal, if there is something abnormal, you can contact your physician's office. A lot of times I think a nurse or nurse practitioner or a physician's assistant if not the physician himself or herself may call you back, talk about your symptoms, talk about what you have found. And then, really the most important thing on this diagnosis or the first step is going to be the ultrasound, and that can be something that could be referred as an outpatient, over the phone, even through a telehealth visit so that you can get on your way to finding out what this is.

But testicular cancer is one of the emergencies that we would say, not that you should go to an emergency room, but it is something that should be diagnosed and clarified even in the setting of a pandemic, if at all possible, without going into the physician's office to get that ultrasound. But, it is something that we would want to know about sooner rather than later, so it is not something to sit on and ignore. So Mike, what are some other recommendations or other guidances that you could give to those listening as they're trying to think through testicular cancer awareness?

Mike Craycraft: I mean, really I think just having a simple discussion. Obviously the person closer to that guy has a better idea of how they will take the message. I remember I had a pediatrician that told me when I was young to do a self-exam, and I remember it to this day but I didn't listen. I walked out to the parking lot kind of laughing, and I think that's probably a reaction most guys would get. But, if they're hearing that message from us in the general public, and they're hearing it from their physician, and they're hearing it from their parents or in the school, the more times they hear it and from different sources, I think it's important. It doesn't necessarily, you don't have to be an expert in testicular cancer just to mention that it does happen, or something as simple as suggesting they download our free self-exam app. I think there's just a lot of stuff, especially with social media, that you can help get the point across to young men without feeling that you have to sit down and have some kind of stern conversation with them.

Alicia Morgans: I think that's a great message and the other piece that I would add as a doctor who treats young men with testicular cancer, that I think cancer, that word, that C-word is really, really scary. Anytime someone's diagnosed with cancer, it is a life-changing event. However, testicular cancer, even after it has spread out of the testicle into lymph nodes or even to other organs is, in many, many cases, in most cases actually, imminently curable. So, a cancer that can be cured even if it spreads and that young men can live basically normal lives after treatment.

But, the most important thing is identifying that cancer and getting to treatments and making sure that you come out on the other end, and talking about it is going to be the first thing. So, remember that in most cases it's going to be curable. There are many young men who go through this, and even with metastatic disease can be happy and have normal lives afterward. But, it is important to come to the attention of physicians.

As we wrap this up, what are the overarching themes or the closing messages you'd like the audience to think about, Mike?

Mike Craycraft: Really, you know, from awareness perspective is just, you know, how can you talk to more young men about the disease? And I don't mean men, obviously, guys are at risk their entire lifetime, but, you know, if we get to them early in life, make them aware that cancer can affect you when you're young, it does affect the testicles, it's very highly treatable if caught early, I think that's kind of the most important thing is, you know, what can you do just on the small scale, try to make a difference.

Alicia Morgans: I totally agree, and to learn more and to think more about this, if you have questions, please go to testicularcancersociety.org. It's a fantastic website that's really user friendly. It gives a lot of information for whatever level of detail you want to have. Also, of course, some humor and things that are just easy to access and to understand, regardless of your age. Remember, any man over puberty, essentially, is potentially at risk for testicular cancer. Self-exams are ways that you can identify something that's abnormal and get checked out, and even metastatic or cancer that has spread, when is when it is testicular cancer can be cured in most cases, so getting yourself to the attention of a physician to take care of this earlier rather than later is going to be really, really important. Thank you so much for your time today, Mike.

Mike Craycraft: Thank you for having me.