Penile Cancer

Facts about penile cancer 

Q1 What is penile cancer?

Penile cancer starts in or on the penis. The penis is the external male sex organ

Q 2 What causes penile cancer? 

  • Infection with human papillomavirus (HPV) is the most common risk factor

Certain sexual behavior can increase the risk of HPV infection, including:

  • Becoming sexually active at a young age
  • Having many sexual partners
  • Having sex with a partner who has had multiple sexual partners
  • Having unprotected sex

High-risk HPV types are more likely to lead to cancer. HPV-16 and HPV-18 are the most common high-risk types. They are linked to penile cancer. Low-risk HPV types, such as HPV-6 and HPV-11, rarely cause cancer, but they can cause warts on or around the genitals.

  • Phimosis

In men who are not circumcised, the foreskin of the penis may become thick and tight and difficult to pull back (retract). This condition is called phimosis.

  • Not being circumcised

Circumcision is the removal of the foreskin. The age at circumcision appears to affect the risk for penile cancer. Men who were circumcised as newborns or children appear to have a lower incidence of penile cancer. Being circumcised as an adult does not appear to provide any protection against penile cancer

Research suggests that circumcision may help promote better penile hygiene, cause less irritation or inflammation of the penis, and lower the risk for penile HPV infection. Circumcision prevents phimosis, which is also linked to penile cancer.

  • Weakened immune system
  • Having HIV or AIDS
  • Taking certain drugs that suppress the immune system (called immunosuppressants) after an organ transplant
  • Smoking tobacco or using smokeless tobacco products (including chewing tobacco and snuff) may increase the chance of developing penile cancer.

Q 3 What are the types of penile cancer?

  • A non-cancerous (benign) condition of the penis 

Non-cancerous conditions do not spread (metastasize) to other parts of the body and are not usually life-threatening. Genital warts (condylomata) are a common non-cancerous condition of the penis. They are a common type of sexually transmitted infection caused by the human papillomavirus (HPV). 

  • Precancerous conditions of the penis are changes to penis cells that make them more likely to develop into cancer. These conditions are not yet cancer. But if they aren’t treated, there is a chance that these abnormal changes may become cancer.

The most common precancerous conditions of the penis are:

  • Penile intraepithelial neoplasia (PeIN)
  • Balanitis xerotica obliterans (BXO)
  • Buschke-Lowenstein tumour
  • Bowenoid papulosis
  • Leukoplakia
  • A cancerous tumor of the penis can grow into and destroy nearby tissue. It can also spread (metastasize) to other parts of the body.
  • Squamous cell carcinoma (SCC). It is the most common type of penile cancer 
  • Adenocarcinoma 
  • Melanoma of the penis 
  • Basal cell carcinoma

Q 4 What are the symptoms of penile cancer?

  • Growth or ulcer on the penis that doesn’t heal within 4 weeks
  • Bleeding from the penis or from under the foreskin
  • Foul-smelling discharge
  • Thickening of the skin of the penis or foreskin that makes it difficult to draw back the foreskin (phimosis)
  • Swelling in the groin because of enlarged lymph nodes 

A word of caution 

All of these symptoms can also be caused by conditions that are not cancer. Kindly consult your doctor first.

Q 5 How is penile cancer diagnosed?

  • Medical history and physical examination
  • If ulcer or growth on the penis is suspected to be cancer, a biopsy is done for confirmation. 

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab.

A word of caution 

  • There is a common myth that taking biopsy leads to the spread of cancer cells in the body. This is not true. Taking a biopsy does not lead to the spread of cancer cells in the body.
  • Biopsy confirms that it is cancer and not infection and also helps in knowing the type of cancer so that further treatment can be planned accordingly. 
  • If lymph nodes in the groin are enlarged then ultrasound-guided FNAC can be done.  

Further testing:  If the biopsy confirms penile cancer, the further test can be done 

  • Blood tests – to assess the state of the liver, and bone marrow
  • Chest X-ray – to check if cancer has spread to the lungs or not. 
  • CT scan of the abdomen 
  • Sometimes a PET scan – To know distant spread of disease 

Q 6 What is penile cancer staging?

Staging is a measurement of how far cancer has spread.

After all the tests have been completed and the results are known, it should be possible to predict what stage the cancer is. The higher the stage, further cancer has spread

  • Stage 1

Cancer has grown into the superficial layers of the skin of the penis, but it has not grown into the blood vessels or lymph vessels (lymphovascular invasion). 

  • Stage 2

Cancer has grown into either: blood vessels or lymph vessels and/or deeper layers of skin of penis and/or urethra

  • Stage 3

Cancer has spread to lymph nodes in the groin (called the inguinal lymph nodes) and the lymph node is able to move when felt by a doctor.

  • Stage 4

Describes any of the following:

  • Cancer has grown into a nearby structure other than the urethra.
  • Cancer has spread to lymph nodes in the groin and has formed a lump that can’t be moved (called a fixed nodal mass) when felt by a doctor.
  • Cancer has spread to lymph nodes in the abdomen (called pelvic lymph nodes).
  • Cancer has spread to other parts of the body (called distant metastasis), such as to the lungs, liver or bone. This is also called metastatic penile cancer.

A word of caution 

The above staging is a simplified version for your basic understanding. The reader is advised to follow TNM staging system developed by the American Joint Committee on Cancer (AJCC) in which 

  • T stands for the size and location of the primary tumor
  • N stands for nodes. It tells whether cancer has spread to the nearby lymph nodes
  • M stands for metastasis. It tells whether cancer has spread to distant parts of the body

Q 7 How penile cancer is treated? 

Penile cancer is often curable if it’s diagnosed at an early stage. Surgery is the only curative option 

When deciding treatment options for a particular patient, doctor will consider following factors and will decide individual treatment plan:

  • The size of the cancer
  • The stage of the cancer
  • The location of the cancer
  • Your overall health and ability to recover from surgery, radiation therapy or chemotherapy
  • The location of cancer on the penis
  • Your personal preferences

Following are the general guidelines but treatment may vary from patient to patient:  

You may be offered one or more of the following treatments for penile cancer.

  • Stage I   

Surgery only: these cancers are usually treated with a partial penectomy with or without surgery to remove the lymph nodes in groin 

  • Stage II & III  

Surgery with or without surgery to remove the lymph nodes followed by chemotherapy +/- radiation therapy

In some cases of stage III, chemotherapy (chemo) or chemo plus radiation may be used first to shrink the tumor so that it’s easier to remove with surgery.

  • Stage IV 

Chemotherapy in the majority of cases. Surgery in a few selected cases only

Surgery

Surgery is the main treatment for penile cancer. Depending on the stage and size of the tumor, you may have one of the following types of surgery.

  • Circumcision removes the foreskin of the penis. This may be all that is needed for a very small tumor located only on the foreskin.
  • Mohs surgery removes cancer in layers, little by little until no cancer remains. It may be used to treat small, early-stage penile cancers.
  • Laser surgery uses an intense, narrow beam of light (called a laser beam) to destroy cancer cells. It may be used to treat small, early-stage penile cancer (carcinoma in situ) or precancerous conditions of the penis.
  • Wide local excision removes the tumor along with a margin of normal tissue around it. It is used for small, early-stage penile cancer.
  • Glansectomy removes the head (glans) of the penis. It may be used for penile cancer that is only in the head of the penis.
  • Partial or total penectomy removes part or all of the penis. It may be used for penile cancer that has spread into the deeper tissues of the penis.