When Lance Armstrong first noticed that one of his testicles was twice as big as the other, the 27-year-old, who just won the Tour de France, did what any red-blooded American male would do. He ignored it. Even when he coughed up blood after cycling through the simmering Texas hills one day, it didn't worry him overmuch. "I'm an athlete, I always have little aches and pains," Armstrong said. "I thought, if I don't do it tomorrow, it must not have been any big deal."
In October 1996, by which time the painful swelling made it hard to mount his cycle, Armstrong went to the doctor and learned he had testicular cancer that had spread to his lungs and brain. That set the ball rolling, as it were, and it ended up in one of the most remarkable comebacks of sport and medical history. Armstrong lost a testicle, underwent four chemotherapy sessions and seven hours of brain surgery. But he rode 30 miles a day between chemo sessions, and within 18 months he was back in the velodrome. Sunday he finished the most famous bike race in the world, a grueling three-week tour of France's mountains and valleys, with the fastest time in race history.
But this wouldn't have happened if Armstrong had gotten testicular cancer 25 years ago. He'd probably be dead. If he'd gotten it 20 years ago, he wouldn't have competed in a Tour de France three years later. In the late 1970s, chemotherapy for testicular cancer lasted up to two years -- as opposed to today's three months -- and was as close to hell as anything imaginable. "I threw up every seven to eight minutes for 12 hours in a row, once every three weeks for a year," recalls Peter Acquaviva of Cincinnati, who beat the cancer in 1979. "You feel like you've been hit by a garbage truck. Your feet and hands tingle. You're so fatigued."
Advances in chemotherapy and other treatment nearly assure survival for
most of the patients diagnosed with testicular cancer nowadays, a fact
obscured by Armstrong -- and most of the press -- when they proclaimed his
accomplishment as downright miraculous.
But "it is absolutely not a miracle," says Dr. Bruce Roth, an oncologist at Vanderbilt University, who was on the team that treated Armstrong at Indiana University. In fact, although he had 40 tumors in his lungs and two in his brain, Armstrong's chances were good from the start -- a counterintuitive statement, but testicular cancer is a counterintuitive cancer. This year, 171,000 people will get lung cancer and 159,000 will die of it; 176,000 women will be diagnosed for breast cancer, and 43,000 will die of it. The survival rate for testicular cancer is currently 95 percent overall, and 50 percent even when the cancer is as widespread as Armstrong's. Ask an oncologist why testicular cancer responds so well to chemotherapy when other cancers do not and the inevitable answer is, "If I knew that, I'd have a Nobel Prize."
Only about 7,500 Americans get testicular cancer every year, but it is the leading cancer among men ages 15 to 35. The survivors owe their lives to a couple of fortuitous research discoveries. In 1965, a biophysicist named Barnett Rosenberg published a paper in Nature noting that the heavy metal platinum killed tumors. Oncologists began trying it out on their intractable cases, but success was mixed and the metal induced horrible bouts of nausea and kidney damage. (Saddam Hussein has used similar poisons to slowly kill his opponents.) The cancer world had largely written off platinum by 1974 when Lawrence Einhorn, a young oncologist at Indiana University, began using it -- in combination with two other potent drugs -- on testicular cancer tumors.
Einhorn, who directed Armstrong's treatment, recalls what happened next: "When they came in for their second chemotherapy treatments, three weeks after the first, the radiologist was just amazed to see that their tumors had melted away. He kept saying, 'What are you doing to these people?'" When Einhorn nervously presented his findings to the American Society of Clinical Oncology in May 1976 (he is currently president-elect of the society), "it led to optimism about all cancers."
But as is the case with so many other silver bullets, the success rate of the "Einhorn regimen" was confined to testicular cancer. "In my own naive mind I thought this is step one toward curing other advanced cancers," says Einhorn. "Unfortunately it's an elusive target." Testicular cancer strikes germ cells -- the precursor cells of sperm. For some reason germ cells develop less resistance to chemotherapy drugs than do other types of cancer cells, and the human immune system is less weakened by testicular cancer. Why this is so "is the $64,000 question," says Einhorn. "I'm just glad that my 15 minutes of fame has allowed Lance to win the Tour de France and thousands of other young men to pursue their own destinies."
This is not to say that testicular cancer is a walk in the park. The inevitable first line of therapy is to lop off the testicle in question. (The procedure, called radial inguinal orchiectomy, actually involves pushing the walnut-sized testis through a pencil-shaped canal into the abdomen, where it is removed.) Doctors order the surgery done immediately after diagnosis because testicular cancer grows fast. The guillotine-like swiftness of the act accounts for the black humor, reeking of testosterone and fear, that prevails in the precincts of this cancer. (As in, "I'd give my right nut to be rid of this cancer. Actually, I did," or in the words of advice given to other men: "Be like a squirrel -- Check your nuts!")
"It happens rather rapidly," understates Acquaviva, who is now 49. "You're a single man swinging free in the city and all of a sudden somebody's gonna whack off your nut. Your response is, 'You want to cut off my what?'" Luckily, the male sex organ is designed redundantly -- with one testicle, you can still get a hard-on and an orgasm -- but some patients report a loss in lust, for sex and life in general.
Depending on the cell type and advance of the cancer, about a third of all testicular cancer patients get radiation. Perhaps half get two to four sessions of chemotherapy lasting up to three months. The chemotherapy regime has improved considerably over the past 20 years, dulling many of the side effects. Experimentation has also introduced flexibility in the types of drugs that can be used. Knowing that Armstrong was a racer who required all the endurance he could get, doctors replaced bleomycin, one of the drugs in the regime, with ifosfamide, because bleomycin, while less nauseating than ifosfamide, can cause lung problems.
Armstrong was also fortunate, in a sense, not to be among the minority of testes cancer patients who require abdominal lymph node surgery. In this procedure, surgeons slice the patient open from breastbone to crotch, removing the internal organs and placing them on the chest in order to reach infected lymph node patches. "It's kind of like gutting a fish but you want the fish to live," says Adam Williams, an auto executive who had the seven-hour surgery this spring. Until recently, when nerve-sparing techniques were developed, the operation resulted in retrograde ejaculation -- into the bladder instead of out the penis. ("Sex is a lot neater and cleaner," says another patient, trying to put a positive spin on it. "No fuss no muss -- no wet spot in the bed." )
One of the ironies of Armstrong's illness is that since his cancer went directly from the testicle into his bloodstream, it threatened his vital organs but not his lymph nodes. Williams, still smarting at the waist, wonders whether Armstrong could have managed a Tour de France-level tour de force after lymph node surgery. "I just can't believe he would have recovered as quickly. Of course, I might feel differently a year from now," he says.
Time is, obviously, critical. If Brian Piccolo of the Chicago Bears had gotten testicular cancer a few years later, instead of in 1969, "Brian's Song" might have had a happy ending. Skater Scott Hamilton, subway shooter Bernard Goetz, Alexander Solzhenitsyn and the panda Hsing-Hsing all survived testicular cancer, but none stepped forward as role models. Armstrong has gripped the role with quiet gusto. Only six months after his diagnosis he set up a foundation to disburse grants for testicular cancer research. And his example is squarely inspirational. "We all but worship Lance Armstrong," admits Rick Glassman, a 40-year-old lawyer in western Massachusetts and testicular cancer survivor. "To proceed after such a traumatic experience clearly requires a Herculean effort," explains David Joel, an artist in New York who also beat the disease. "It is in the nature of this illness to hit us directly in the part of the body responsible for Herculean effort ... To do what Lance has done, to conquer the potential limitations of his physicality, is that much more phenomenal."
"Lance is huge," says Rick Hyman, a 43-year-old Los Altos, Calif., salesman and amateur cyclist. Hyman found out in May 1998 he had testicular cancer after being misdiagnosed for two months. "I got on the Internet the morning I found out, sent a message to the foundation, they forwarded it to Lance, and he got back to me immediately saying, 'You know, I'm not saying your docs are bad but you might want to get a second opinion.'" When Hyman called one of Armstrong's physicians at Indiana University, the leading testicular cancer treatment center in the United States, he discovered that Armstrong had primed the doctor, who immediately agreed to see him.
A year later, Hyman was well enough to compete in the Ride for the Roses, an annual Austin, Texas, race. "I asked Lance why he set up the foundation," says Chris Brewer, who runs two Web sites for patients, "and he just kinda looked at me and said, 'If you can help somebody, you should help somebody.'"
Armstrong is about to face another challenge in October, when he becomes a father for the first time. He banked his sperm before undergoing chemotherapy -- which causes temporary and sometimes permanent infertility -- so his wife became pregnant via in vitro fertilization. There is an ever-so-slight chance of a relapse in years to come -- Einhorn puts it at 2 percent -- but even relapses, in testicular cancer, can be treated. "All of our patients do remarkable things. The truly remarkable thing about someone like Lance is that he came back to his sport with incredible mental and physical toughness," says Einhorn. "This is a very, very determined young man."