Iowa Alumni Magazine | December 2004 | Features

A Low Blow

By Kathryn Howe

Thoughts of illness and death do not occupy the mind of the average 22-year-old male. At that age, the future sprawls out ahead, vast and brimming with endless possibility.

Sadly, there’s a specter that can intrude on that future, destroying any feelings of invincibility and a young man’s sense of virility and self. Protected by his tendency to ignore it, the quiet apparition possesses his body and begins to spawn its poison. Just ask Lance Armstrong.

UI pharmacy student Leigh Boehmer grew in courage and compassion when he faced a troubling diagnosis.

Or Leigh Boehmer, today a second-year pharmacy student at the University of Iowa, who first noticed a pea-sized lump while he was in the shower, six months before excruciating pain finally sent him to a doctor. That lump turned out to be testicular cancer, the most common malignancy in young men between the ages of 15 and 35. Every year, doctors diagnose 7,500 new cases in the United States. And, although it accounts for only one percent of all male cancers, the disease carries a disproportionately large societal impact because it kills more men in the prime of their lives than all cancers combined.

“I remember thinking, ‘I know I should do something about this,’” says Boehmer, of when he discovered the lump on the upper front of his right testicle. “A combination of denial and concern about what it could mean kept me from calling the doctor.”

Looking back, he wishes he’d reacted differently. But he wants other men to know that his story doesn’t have to be theirs. Thanks to the efforts of national public figures such as six-time Tour de France champion Lance Armstrong and outspoken community-level survivors such as Boehmer, Iowa football freshman Brock Ita, and Iowa State quarterbacks coach Todd Fitch, testicular cancer is receiving the kind of attention and exposure that advocates hope will prove as life-saving for men as the breast cancer awareness campaign has been for women.

“I tried to think of cancer as a gift because it was a call to action for me,” Boehmer says. “I prayed for the chance to share my experience with others. I didn’t know anyone with testicular cancer before this, and I want people who get it to know they aren’t isolated or alone.”

During finals week in spring 2002, shortly after he received a much-anticipated letter of acceptance to Iowa’s College of Pharmacy, Boehmer complained of pain on his right side, but declined to follow his best friend’s advice and see a doctor. He figured it wasn’t a big deal. After all, he was a 22-year-old college student. How could he be sick? The Tuesday after exams, though, Boehmer awoke in so much agony that he began vomiting and couldn’t go back to sleep. The pain had migrated to his groin area, and there was simply no more procrastinating. He made an appointment, convinced he suffered from kidney stones. He hadn’t urinated in two days.

After conducting a thorough physical, the doctor collected blood and urine samples and then dispatched Boehmer to Iowa City’s Mercy Hospital for a CAT scan. When the doctor called him back to the office a few hours later to interpret the test results, Boehmer’s heart raced: “At that moment, I knew something was wrong.” The next few moments set the course for the longest day of his life.

The blood work, coupled with a scan that showed a fist-sized abdominal mass, suggested two possible causes: testicular cancer or non-Hodgkins lymphoma. Boehmer needed a cancer specialist and received a referral to James Feeley, 85R, 87F, at the Iowa City Cancer Center, who rendered a diagnosis of “advanced late-stage nonseminoma testicular cancer.” Undetected for months, the disease had spread from the testicle to the retroperitoneal area behind Boehmer’s right kidney and into his lungs. This did not mean that Boehmer had lung cancer as well. The type of cancer a person faces depends on where it originates—not where it ends up.

Shocked, Boehmer frantically tried to process the news his doctor delivered. As the sun set and the appointment continued into the evening hours, he felt as though time had stopped. He ached at the thought of calling his mother.

Ita could relate to that feeling. Although his mother, father, and best friend accompanied him to the doctor’s office for his diagnosis, he left them in the waiting room during the consultation: “I couldn’t bear to see my parents’ reactions,” the 19-year-old recalls. “I think dealing with the lump for so long prepared me for the bad news. My parents took it a lot harder than I did, but that’s to be expected because parents are so protective of their children.”

Although the jolt of hearing he had cancer overwhelmed Boehmer, his doctor quickly turned attention to the positive: “From day one,” says Feeley, “I tell my patients that there isn’t a doctor in the world who wouldn’t approach this from the standpoint of curing it.” Feeley explained his plan of attack, starting with the first line of defense in any case where testicular cancer is suspected: removal of the testicle (orchiectomy). In the course of one week, Boehmer came to terms with a cancer diagnosis, had his right testicle removed along with a spermatic cord, and began a course of chemotherapy. Feeley gave him a 70 percent chance of cure.

Testicular cancer is 4.5 times more common among white males than blacks, and the causes are not well understood. As Boehmer and Ita experienced, patients tend to detect a problem when the cancer presents itself as a painless or uncomfortable lump in the testicle. Early symptoms are mild, mistakenly leading many men to believe their discovery is harmless or that it will go away. Boehmer’s lump disappeared after a week, so he assumed it was nothing. As it turns out, though, a primary tumor can break away from the testicular area and spread. This is a cruel trick because, if found early, testicular cancer is almost always curable.

Ita’s lump persisted, but he still tried to put it out of his mind. “I thought that some days it would be smaller than others,” says Ita, who first noticed the mass in spring 2004. “I wanted to make it through the summer because of football workouts; I wanted to compete for a spot.”

If testicular cancer is treated before reaching the lymph nodes, the cure rate is more than 98 percent. Even patients with late stage disease stand a good chance of recovery, although their treatment is more complicated and intense. Depending on the stage and type of development, testicular cancer is effectively treated with surgery, radiation, and/or chemotherapy.

“If you look at the entire group, well over 90 percent are cured, which is a spectacular result considering that 30 years ago testicular cancer was fatal for half of all patients,” says Dr. Michael O’Donnell, director of urologic oncology at UI Hospitals and Clinics. “This is the example of what we want to do for all cancers.”

Testicular cancer is so treatable because it’s derived from a unique population of cells that are extremely sensitive to radiation or chemotherapy, O’Donnell explains. It also happens to be one of the most rapidly proliferating cancers—another characteristic that makes the disease very susceptible to agents that can interrupt growth. Picture a log (chemotherapy) rolling into the path of a speeding car (the cancer), forcing the vehicle off track and into a ditch.

Cyclist Lance Armstrong poses with UI graduate Dr. Lawrence Einhorn at Indiana University during the Tour of Hope celebration on October 16, 2003.

The most significant advancements in understanding and treating this disease come from Iowa grad Lawrence Einhorn, 67MD, who developed the potent chemotherapy cocktail BEP (bleomycin, etoposide, and cisplatin) that stops the cancer in its tracks. Einhorn, a distinguished professor of medicine in the testicular cancer care program at Indiana University-Purdue University Indianapolis (IUPUI), reached a further degree of fame when he treated Lance Armstrong for an extremely malignant form of testicular cancer that had metastasized to the cyclist’s brain.

Immediately after having his testicle removed, Boehmer, who deferred his admission to pharmacy school for one year, endured four three-week cycles of BEP chemotherapy. He was the youngest person at the cancer center by 30 years. The grueling daily treatment sessions lasted a full eight hours. As the chemicals accumulated in his body, he grew sicker and sicker. He lost 40 pounds and ended up in the hospital with anemia. Ulcerated sores multiplied in his mouth and spread down his esophagus. Boehmer vomited eight, sometimes 12 times a day. He lost his hair, but not his hope, and simply refused to get depressed or feel sorry for himself.

By the middle of August 2002, the chemotherapy had killed all the cancer in Boehmer’s body. He then traveled to Indianapolis so surgeons could remove the shrunken, dead tumor in his abdomen and also the surrounding lymph nodes, a complicated medical procedure known as RPLND (retroperitoneal lymph node dissection). To Boehmer’s great surprise, Einhorn himself strode into the hospital room and asked him to name his favorite omelette from the Hamburg Inn.

“The Iowa No. 4,” Boehmer replied without hesitation. Satisfied with that answer, Einhorn patted him on the shoulder and said, “Son, you’re going to be just fine.” It was true. The lump in his belly gone, Boehmer’s tests for residual cancer came back negative. Cancer-free for two years now, he continues to have regular checkups every three months with Feeley, who corresponds with the doctors in Indiana. Eventually, Boehmer will work his way down to annual checkups. After five years without cancer, the chances of recurrence will significantly drop.

“This experience showed me the power of people working together toward a common cause—that people are truly good and there’s more that links us than could separate us,” Boehmer says. “I would never glorify cancer, but I was afforded an opportunity. I learned to never ever take a second for granted. Cancer taught me to say ‘I love you’ every time I walk out the door.”

Thanks to an insistent friend, Brock Ita went to the doctor; and, thanks to his excellent physical condition, he came through his cancer surgery and chemotherapy just fine--although the Hawkeye defensive back lost his hair in the process.

Ita, who has rejoined the Hawkeye football team in Iowa City, also re-evaluated his appreciation for life after his brush with cancer. “When you go through something like this, the little things become very important,” says Ita, who underwent surgery and two rounds of chemo to end his cancer. “Being so young, you also think about how great life is. To other young guys out there, my advice is: don’t wait. Take care of yourselves. You can be the healthiest guy around and this stuff can still get you.”

Although testicular cancer’s causes remain somewhat a mystery, O’Donnell says there are a few notable risk factors. Men with undescended (or abnormally developed) testicles or a family history of testicular cancer have an increased risk. Also, men with the sex chromosome disorder Klinefelter’s syndrome or whose mothers took the nausea drug DES during pregnancy may be more susceptible. But mostly, testicular cancer is a random occurrence. As to why it strikes men at such a young age, O’Donnell says puberty may play a role. The onset of puberty coincides with many transformations in the testicle that drive germ cells to grow. These cells have the potential to develop into any type of tissue, so any break in their chromosomal or genetic makeup can set the stage for cancer development, he says.

Ninety-five percent of all testicular cancers are germ-cell cancers. Of these, there are two kinds: seminomas—which tend to spread in a typical pattern—and nonseminomas, which move along a more unpredictable course and can require more aggressive treatment. Blood tests, scans, and biopsies are critical to determine what type of cancer a person has and therefore the best treatment approach. Feeley points out that removing and studying the affected testicle is vital to this process, and that is unlikely to change.

For such reasons, O’Donnell admits, it’s a real challenge to treat young men with this disease. Not only does testicular cancer threaten their health, it threatens their manhood. They face questions of virility and fertility. While both doctor and patient must put their immediate focus on diagnosis and treatment, they should also address the cancer’s impact on a man’s sexuality. Many patients are relieved to learn that removing a testicle has no impact on a man’s sexual function or fertility. That’s the good news. The bad news is that the RPLND procedure can impact ejaculation and contribute to sterility, while chemotherapy and radiation can affect sperm production and viability. Still, men faced with those treatments can bank their sperm and preserve their ability to have children, as Boehmer did. And, for men worried about the aesthetics of having only one testicle, prostheses are available. O’Donnell hopes that public education will help men realize that their fears can be resolved.

“The last thing you expect to hear when you’re 20 years old is that you have cancer,” O’Donnell says. “It’s devastating, but so many tragedies that could result—the tragedy of not following up for care, of not having a family, of recurrence—can be avoided.”
O’Donnell stresses the importance of testicular self-examination, also known as TSE (see sidebar for the correct procedure). Discovery of a lump, an unusually swollen testicle, or anything that seems different should prompt a man to seek medical attention immediately. Boehmer encourages others to learn from his mistakes and not to ignore signals that something is amiss.

Thankful for his second chance, Boehmer participates in various cancer research fund-raisers, including Lance Armstrong’s Tour of Hope cross-country bicycle ride and the Johnson County Relay for Life. He also supports clinical trials and recently completed one at IUPUI on the effects of RPLND surgery. Above all, he hopes that sharing his experience will teach us all to take responsibility for our own health.

“When we think of cancer, we think of pediatric patients and the elderly,” he says. “But the truth is, cancer can happen to anyone.”