Penis Cancer Treatment Decisions Often Misguided

Pam Harrison

March 19, 2018

COPENHAGEN — For approximately one-quarter of men with penile cancer, survival is significantly compromised because the treatment they receive does not adhere to evidence-based recommendations, new research shows.

"When we looked at the reasons physicians were not following the guidelines, we found that the decisions were made by both surgeons and patients, and that they were not necessarily arbitrary decisions," said investigator Luca Cindolo, MD, from the robotic urology unit at ASL Lanciano Vasto Chieti in Abruzzo, Italy.

"When we face penile cancer, we are up against a disease that is very destructive from a social point of view, a sexual point of view, and even from a psychological perspective," Cindolo told Medscape Medical News.

Early-stage penile cancer has a good prognosis, with 80% to 90% of patients surviving out to 5 years; however, for men with more advanced disease that has spread to the lymph nodes, 5-year survival is only about 20%.

For penile tumors in the early stages, treatment can consist of laser ablation of the lesion — an approach similar to that used for dermatologic malignant lesions — which completely spares the penis. But as the tumor advances, treatment might involve partial or complete amputation, wider excision margins, removal of the testicles, or even perineal urethrostomy.

Rare, Distressing Cancer

Penile cancer is rare in North America and Europe. It is diagnosed in less than 1 man in 100,000 each year, and accounts for less than 1% of cancers in men in the United States. Penile cancer is, however, much more common in some parts of Africa, Asia, and South America.

"For patients, treatment is often a very difficult decision, and sometimes they choose to die of the disease — but with dignity — rather than face amputation," said Cindolo, who presented the study results here at the European Association of Urology (EAU) 2018 Congress.

He and his team reviewed the medical records of 425 patients who had undergone treatment for penile cancer at one of 12 centers in the United States, Brazil, Hungary, Italy, and Spain to assess adherence to 2016 EAU guidelines.

They looked at demographic characteristics, comorbidities, circumcision, site of primary lesion, perioperative data, and histopathologic data. Patients themselves reported follow-up updates.

Men in the study cohort were treated with different surgical approaches: 48% underwent partial penile amputation; 23% underwent tumor excision; 9% underwent glansectomy; 13% underwent total emasculation; and 6% underwent radical circumcision.

Rates of adherence to recommendations for primary surgery and for lymphadenectomy were similar (74.8% vs 73.0%).

EAU recommendations were not followed in 17% of men because of patient choice, in 52% because of surgeon choice, and in 31% because of other reasons.

After adjustment for adherence to lymphadenectomy recommendations, age, tumor stage, the presence of palpable nodes, and tumor grade, overall survival was 54% better for patients treated in accordance with EAU recommendations than for those who were not (P < .023).

Penile cancer progresses rapidly, Cindolo pointed out, so a noninvasive manageable intervention that could be used early on can lead to something much more invasive with a delay of only a few months.

Because there is no screening program and no campaign to teach men when they should seek medical attention for any abnormalities of the penis, the best strategy to improve the management of penile cancer is to target surgeons, Cindolo said.

"Centralization," such as the specialized treatment centers that now exist in the United Kingdom, "is one possibility," he noted.

If we treat rare cancers in national or even international centers of excellence, chances of better management improve.

Alternatively, a focus on the training of surgeons so they are better prepared to manage penile tumors would be helpful. These surgeons could then go on to perform a high volume of the surgeries themselves.

Patients with rare cancers, including penile cancer, often get short-changed because doctors have never or have seldom seen anything like it before, said Vijay Sanger, MD, from Christie Hospital in Manchester, United Kingdom.

"If we treat rare cancers in national or even international centers of excellence, chances of better management improve," he said in a statement.

In the United Kingdom, the treatment of penile cancer occurs in only 10 centers of excellence, he reported. However, in other countries, that kind of center is rare, and men are still treated locally by urologists who are likely unfamiliar with optimal surgical techniques.

The recently established eUROGEN consortium, a reference network for rare and complex urogenital diseases and conditions, will likely have a major impact on patient care in Europe, Sanger explained. It will give patients with rare urologic diseases access to optimal management, no matter where they are located, he added.

Cindolo and Sanger have disclosed no relevant financial relationships.

European Association of Urology (EAU) 2018 Congress: Abstract 24. Presented March 16, 2018.

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