279 Penile Cancer Survivorship Challenges and Issues
Cancer of the penis is a rare genitourinary malignancy with a low incidence in Europe and North America (<1 per 100,000), but with a significant presence in South America, Southeast Asia, and Africa, where there is an annual incidence of 2.3 to 8.3 per 100,000 (1). The majority of the malignant penile tumors are classified as squamous cell carcinoma and originate from the inner prepuce, sulcus, or the glans of men in their sixth decade of life. The presence of phimosis and uncircumcised foreskin is strongly associated with penile cancer (odds ratio 11.4) (2). This cancer carries a poor prognosis once it has metastasized and reached advanced stages, but local occurrences can be cured in up to 80% of cases.
Prevention strategies play a unique role in penile cancer management. The majority of the known risk factors are patient dependent and modifiable. For instance, cigarette smoking, presence of uncircumcised foreskin, phimosis, and chronic inflammation have all been identified as common and important risk factors for the development of penile cancer. All of these factors can be modified and controlled with corresponding reduction in the relative risk of associated cancer. The practice of circumcision has been shown to reduce the incidence of penile cancer, but the benefit is only detected when it is performed in the neonatal or prepubertal period, and not during adulthood (2). Indeed, the incidence of penile cancer is lower in regions where the practice is common in neonates. Human papillomavirus (HPV) infection has also been shown to have a clear association with genital warts and genital cancers in both men and women. The advent of the HPV vaccine has led to a substantial decrease 280in HPV related cancers in women. Although studies have yet to show a similar decrease in men, it can be inferred that increasing HPV vaccination rates among men could greatly reduce the incidence of penile cancer (3). However, in many areas penile cancer is also associated with poor socioeconomic status, and this is perhaps one of the strongest barriers against the implementation of effective prevention strategies.
Treatment for penile cancer has evolved in recent years. With greater concern for preservation of both the urinary and sexual function, and also increasing awareness and attention to the psychological impact of the disease, a series of new techniques have been adopted in the management of these tumors. Especially in the early stages of the disease, less invasive surgical strategies were developed to address both the primary tumor and the regional lymph nodes. The goal was to maintain the oncological adequacy of treatment while reducing the morbidity of the radical surgical resections (4). This is a critical aspect related to the quality of life of penile cancer survivors, and is greatly impacted by the type of treatment that they receive. In patients undergoing minimally invasive procedures such as laser ablation or glansectomy, sexual function is maintained in a good proportion of the penile cancer survivors, reported to be 100% and 79%, respectively. After partial penectomy, although over 50% of patients still reported enough erectile function to allow sexual intercourse, there was a marked reduction in sexual satisfaction (2). In total penectomy patients, phallic reconstruction is the only option for regaining sexual function. Whichever treatment is chosen, practitioners should pay special attention to their patients’ psychosocial needs during the management of this disease. Most treatment providers don’t spend much time discussing sexual function and assessing feelings of shame or inadequacy after treatment, but these issues must be addressed for patients to regain their quality of life. As part of a multidisciplinary team approach, psychological assessment before treatment and during the continued follow-up period is a critical component in this population.
Recurrence rates depend on the disease stage at presentation and the chosen method of treatment. Local recurrence is highest when associated with organ-preserving treatment strategies, with a rate of up to 27% in the first 2 years. Therefore, it is imperative that these patients have a close surveillance 281follow-up during the first 2 to 3 years after treatment. For patients undergoing partial penectomy, the risk of local recurrence is much lower, at 4% to 5%. Nodal recurrence rates are very low in patients with negative nodes after invasive staging (2.3%), while in those with positive nodes without adjuvant treatment the risk is as high as 19% (2). Recurrence in the inguinal region represents very poor prognosis, with median survival less than 6 months. Pelvic lymph node metastasis is an ominous finding, with a 5-year survival of 10% (5, 6). Overall, most recurrences will occur within the first 2 years (74%) and almost all within the first 5 years of follow-up after treatment (92.2%). For this reason, the European Association of Urology recommends that all patients undergo follow-up for at least 5 years, with a more intensive period in the first 2 years.
An adequate follow-up schedule is dictated by the initial stage of the primary tumor, the status of regional lymph nodes, and the initial treatment modality received. In all patients it should include a clinical exam of the penis and the bilateral inguinal regions. Routine imaging may not be indicated in patients with early stage of disease and negative groins, but it may help in obese patients where physical examination is limited, or upon positive clinical findings. For patients with N2 or N3 disease, routine imaging of chest, abdomen, and pelvis is recommended at regular intervals (3–6 months) in the first 2 years of follow-up and at the discretion of the treating physician thereafter (2).