Shortly after his 30^th birthday, David noticed a lump on one of his testicles while showering.

“It had probably grown within a week to an abnormally sized testicle from what I would call normal,” he says.

“Later I was told the change in size was due to what’s called a hydrocele, a collection of fluid in the scrotum.

“Although I wasn’t doing any self-checks, I was quite aware of my body and things that shouldn’t be there, and the things I should be checking up on. I was lucky – a testicular lesion shows up quite obviously, but it is up to the person to find out if it’s benign or malignant.”

After two weeks, David realised something wasn’t right – his testicle had doubled in size, and it was slightly painful and unsightly. “I had to do something about it,” he says. He went to his GP who referred him to a urologist.

Cancer – now what?

David had an ultrasound and some blood tests. He was given a course of antibiotics and told to return for a follow-up in 10 days.

“I knew something was up and it wasn’t a bacterial infection,” David says. “It got me thinking over the next few days about the real impact to come. When I saw the doctor again, I had prepared myself for the worst.

“When he mentioned it was cancer, I froze for a moment and then responded without hesitation: ‘How do we beat it?’” 

David’s treatment plan

After many consultations and assessments, David’s doctors put him on a chemotherapy regime.

“My vocabulary increased quite a bit during the journey. I believed in order to beat it, I had to know what was what; I had to name it, shame it and know what was being done to me. I didn’t know it then but there are quite a few ways to ‘cure’ this type of cancer, so they aren’t always the same and it depends on your particular case and what stage you are at.

His diagnosis was Stage 2 germ cell non-seminoma, which had metastasised (spread) to his abdominal and pelvic regions.

“I had three consecutive days of a cruel three-part cocktail,” David explains. “It started with Etoposide for half an hour, followed by Cisplatin (the so-called magic silver bullet to kill the cancer or spreading of it) for 45 minutes and then a gruelling eight hours of Bleomycin.”

David endured three cycles of treatment with a week and a half’s break in between. He experienced side effects that included hair loss, mouth sores, loss of appetite and a change in how food tasted.

“Apple juice, especially, tasted funny and I craved more junk foods than usual.”

Life lessons

“Going through the journey itself, I would say I was very fortunate as I was young and healthy. I did have some bad habits – the typical South African ones of binge drinking and occasional smoking – but those are now gone. Now I’ve become an athlete (well triathlete) and pay a lot of attention to my health.

“Focus on your diet and be as healthy as possible, and get over the experience emotionally. Stay away from negative people and harmful substances and bring it all down into bite-sized chunks you can manage. It is a mountain that can be climbed, and learnt from.”

Early detection saves lives

The five-year survival rate for testicular cancer is more than 90% when testicular cancer is diagnosed while still confined to the testicle.

Unfortunately many men will wait months before seeing a doctor.

Health24 previously quoted Dr Jay Raman, chief of urology at Penn State Medical Centre, who said: “I think part of it is the macho man complex – that everything is fine. Then you add on top of that the fact that it is a sensitive area, and they may have some embarrassment about it.”

Touch your testicles

All men should do a self-examination at least every six months.

You need to check that both testicles have the same contours (smooth and soft) and have the same kind of consistency as a hard-boiled egg or the palm of your hand. Sometimes the testicle can become swollen and grow bigger, and some men have reported having a heavy aching feeling around their scrotum area or lower belly.

If you notice anything out of the ordinary – lumps or bumps, one testicle feeling different to the other, pain, a heavy feeling – don’t feel embarrassed and see your doctor immediately. 

Read more:

Early detection key to beating testicular cancer

Subfertile men more likely to develop testicular cancer

Testicular cancer can affect anyone

Mandy Freeman

Biologics are a new kind of medicine, not produced chemically, but made from a variety of natural resources.

Biologics are complex proteins and biotechnology is used to make them. To put it very simply, the process involves getting living cells to make proteins, and this is not only complicated, but also often not successful. They are not chemically produced in a laboratory, as many other medicines are.

What are biologics used for?

Biologics can be used to treat conditions for which other treatments are not available. In different forms, biological medicines have been around for a long time: insulin treatment and certain vaccines fall into this category. Biologics are used more and more often these days to treat non-communicable diseases, which are more widespread.

For some people with complex and rare diseases (as well as some not-so-rare diseases) biologic drugs from the last decade or so are a last refuge of hope. Some of the most baffling diseases, such as cancer and autoimmune diseases, are best treated with biologics. But the high cost associated with them is currently in the news, as the vast majority of South Africans are unable to access these medicines.

For women with a specific form of breast cancer (HER2 positive), a 12-month course of the biologic medicine Herceptin (as it is called in SA) can cost close to R500 000 per year. The biologic medicine for rheumatoid arthritis is called Enbrel, and can costs R4 800 – R9 404 per injection, depending on the strength needed.

Your medical scheme and biologics

Clearly, most South Africans will not be able to pay for this, and many medical schemes are also unable to afford these medicines for their members. But if the condition you have is a prescribed minimum benefit (PMB), and there is no alternative treatment available, the scheme will have to foot the bill. The state hospitals are bound by the same rules. 

This could have a serious effect on other members, as payment for these medicines could deplete the reserves of the scheme. When PMBs were introduced (with the Medical Schemes Act of 1998), high-cost biologic medicines were not yet freely available, and the knock-on effect of their high cost therefore not considered when passing the legislation. 

More and more schemes are now introducing a separate benefit for biologic medicines, but before these are paid for by any scheme, very specific clinical guidelines are followed. The proven efficacy of the medicine for the particular condition being treated, as well as the availability of treatment alternatives are considered before the green light is given. 

Mediscor, a managed healthcare company that manages the medicines claims for 32 medical schemes, said that their expenditure on biologic medicines rose by 29.7% between 2010 and 2015. Cytostatics, a type of cancer medicine, accounted for 6.7% of the medical expenditure in 2015, but only 0.3% of the total items claimed.

The ethical issues

A debate has been raging in the press on the high cost of these biologic medicines, with consumer organisations blaming pharmaceutical companies for being greedy, and putting effective treatment beyond the reach of people who need it.

The pharmaceutical companies cite the high development and research costs in their defence. They are, after all, businesses. These issues are not new to South Africans – for many years the high cost of ARVs put these beyond the reach of millions of South Africans who were HIV-positive. It raises the ethical issue of putting a cost on someone’s life – a debate that has been ongoing for centuries. The following ethical questions have arisen:

What role do patent laws play in the high cost of these drugs?

Generally, a patent on a medicine developed by a pharmaceutical company is held by the company for 15–20 years, after which these medicines may be “copied” and sold by other pharmaceutical companies, who pay the originator companies a license fee. These “copied” medicines are called generics and are equivalent in dosage and strength and performance to the original medicine. As the second company did not have to carry the research and marketing costs, they can afford to manufacture and sell the medicine at a much lower cost.

Why are biologics so expensive?

There are a few reasons for the high cost of biologic medicines. The research and development costs are extremely high and the testing and manufacturing process is lengthy and complicated. There are eight stages to developing a new medicine from start to finish, and, only one in every 5 000 new medicines make it through from discovery to licensing, says Roberto Solari, a senior research fellow at the Imperial College in London.

This process takes years and costs billions. Unlike medicines made from chemical compounds, biologic medicines are made from natural resources and the failure rate of the manufacturing process is high. Many biologics also target rare diseases, so the market for them is small.

Are there generics available for these drugs?

Generic medicines are bioequivalents for originator drugs – in other words, they have the same active ingredients, and work in the same way. Because of the complicated manufacturing process of biologics, they are difficult to replicate. Once a patent expires, other companies can make what is called “biosimilars” which are generally much cheaper than the original biologics, but they are still relatively expensive to produce.

How are the prices of medicines determined in SA?

International drug patents are applicable everywhere. Apart from those, South Africa has a single exit price (SEP) mechanism in place which determines the maximum price at which medication may be sold. Dispensing fees pharmacies can charge are determined by the SEP. In practice, this means that everyone (the state as well) pays the same for particular medicines – and that includes biologics medicines.

More and more non-communicable diseases (NCDs) such as arthritis, diabetes and heart disease can now be treated with biologics. With four of the top ten leading causes of death in SA being NCDs, the debate on the high cost of biologic medicine, and how this can be reduced, will clearly not be over anytime soon.

Read more:

Biologics and breast cancer

Difference between small chemical products and biologics

Biologics not a cure-all, says scheme

Susan Erasmus