Testicular Cancer Awareness Month: Advances and controversies in testicular cancer care

The field of testicular cancer has seen several notable advances in recent years, which have led to a substantial increase in the cure rates for advanced disease.¹ However, challenges remain in determining which patients are at risk of recurrence, as well as in managing psychological well-being and long-term quality of life for these patients.

In recognition of Testicular Cancer Awareness Month this April, Vladimir Hugec, MD, connected with Urology Times® to discuss the current treatment landscape for patients with testicular cancer. Notably, he highlighted emerging biomarkers such as miR-371a-3p, the shift toward precision medicine, and the need to focus more intently on survivorship care.

Vladimir Hugec, MD

According to Hugec, the field must now think beyond a cure, focusing instead on holistic, patient-centered approaches that take into account the burden of treatment on quality of life, fertility, and mental well-being.

Hugec is a medical oncologist and hematologist at Minnesota Oncology in Maplewood.

Urology Times: How would you describe the current landscape of testicular cancer care in terms of both progress and challenges?

Hugec: Testicular cancer represents a paradigm of curable solid tumors, with survival exceeding 95% in localized disease and over 80% even in metastatic settings. This success is due to the integration of cisplatin-based chemotherapy, robust multidisciplinary care, and advances in surgical technique.

However, challenges persist:

• Risk-adapted therapy is still evolving, especially in stage I disease.
• We lack tools to predict which patients are at highest risk of relapse or toxicity.
• Survivorship issues including cardiac risk, fertility, and mental health require more attention.
• Access remains inequitable, both within and between countries.

We’ve achieved a lot, but the focus now must shift from cure alone to comprehensive, patient-centered care.

Urology Times: Are there any recent advancements in imaging or biomarker development that you find particularly promising?

Hugec: One of the most promising developments is the emergence of microRNA-based biomarkers, particularly miR-371a-3p, which has demonstrated high sensitivity and specificity in detecting viable germ cell tumors. It has clear advantages over conventional markers—AFP, beta-hCG, and LDH—and could soon become central in surveillance and post-treatment assessment.

From an imaging standpoint, although PET/CT remains important in seminoma, especially for residual masses [greater than] 3 cm, it's not without limitations. Innovations in radiomics and AI-enhanced image analysis may soon enhance our ability to differentiate between fibrosis, teratoma, and viable tumor—something current modalities struggle to do effectively.

Urology Times: What is your perspective on the role of microRNA biomarkers in testicular germ cell tumors—are we close to seeing them in routine clinical use?

Hugec: Clinical integration is approaching rapidly. miR-371a-3p is one of the most validated biomarkers in solid tumor oncology today. Prospective studies have confirmed its utility in detecting active disease and predicting relapse. The remaining barriers are largely infrastructural—standardizing the assay, obtaining regulatory approval, and integrating it into existing clinical pathways.

Within the next 5 years, I anticipate we’ll see miR-371 become a routine adjunct in several areas, including surveillance of stage I patients, evaluation of residual masses, [and] detection of minimal residual disease post-therapy.

Urology Times: Are there any controversial topics in testicular cancer management that deserve more open discussion in the field?

Hugec: Yes, there are a few worth discussing. One is the balance between active surveillance and adjuvant therapy in stage I disease, especially for [nonseminomatous germ cell tumor] NSGCT. Although surveillance avoids over-treatment, relapse rates (approximately 30%) and anxiety levels are not negligible.

Another area is the management of post-chemotherapy residual masses, particularly in nonseminoma. Our current imaging tools often cannot reliably differentiate fibrosis from teratoma or viable cancer, leading to either unnecessary surgery or missed disease.

Other critical but under-discussed topics include:

• The long-term burden of therapy (cardiovascular toxicity, neurotoxicity, fertility),
• Disparities in access to high-quality care, especially globally,
• The need for comprehensive and personalized survivorship strategies.

Urology Times: What areas of research are you most excited about in the next 5-10 years?

Hugec: There are several compelling directions:

• Molecular and liquid biopsy biomarkers, especially miR-371 and circulating tumor DNA, which could revolutionize surveillance and early detection.
• Genomic and epigenomic profiling of refractory tumors, which may yield new therapeutic targets
• Targeted therapies and immunotherapy for platinum-refractory disease—still experimental but promising in select patients.
• AI and radiomics, particularly for more accurate imaging interpretation and recurrence prediction.
• Survivorship-focused research, especially addressing long-term quality of life, fertility preservation, and psychosocial outcomes.

Urology Times: Do you foresee precision medicine playing a role in testicular cancer treatment algorithms in the near future?

Hugec: Yes, definitely. We are moving into an era where precision oncology will inform both escalation and de-escalation of therapy.

For example:

• Molecular profiling may help guide more selective use of chemotherapy or identify patients who can safely avoid surgery.
• In refractory cases, genomic and immunologic characterization may open the door to novel agents.
• Biomarkers like miR-371 could enable real-time treatment monitoring, replacing or supplementing imaging.

We’re just beginning to scratch the surface of what precision medicine can offer this population.

Urology Times: How do you currently approach patient selection and decision-making around post-chemotherapy retroperitoneal lymph node dissection (RPLND)?

Hugec: It’s a nuanced decision based on several factors. [A] residual mass [greater than] 1 cm in nonseminoma, with normalized markers, often warrants RPLND due to risk of teratoma or viable tumor. We use imaging characteristics, histology, and clinical course to guide this, although current imaging is imperfect. The procedure should be performed in high-volume centers, and in select cases, a modified template approach may be appropriate to minimize morbidity. Importantly, persistent tumor marker elevation post-chemotherapy typically warrants further systemic therapy, not surgery.

Urology Times: Is there anything else you'd like to add?

Hugec: One final point to emphasize: Testicular cancer is a model for curable cancer, but we need to think beyond a cure.

The next phase should focus on:

• Smarter, not harder, treatment strategies with emphasis on personalized treatment pathways,
• A deep investment in survivorship care, including sexual health, fertility, and psychological well-being,
• A commitment to global disparities, because a cure should not depend on geography.

We have a chance to lead by example in how we approach survivorship, equity, and precision care in oncology and urology.

REFERENCE

1. McHugh DJ, Gleeson JP, Feldman DR. Testicular cancer in 2023: Current status and recent progress. CA Cancer J Clin. 2024 Mar-Apr;74(2):167-186. doi:10.3322/caac.21819