Cancer of the penis (penile cancer)

Cancer of the penis

Cancer of the penis is rare in Europe and the USA, but is more common in South East Asia, parts of Africa, and India. Approximately 600 men are diagnosed with this type of cancer each year in the UK. It is most often diagnosed in men over the age of 60 years.

Causes

The exact cause of cancer of the penis is not known. It is thought to be related to general hygiene and is much less common in men who have been circumcised (had all or part of their foreskin removed) soon after birth. This is because men who have not been circumcised may find it more difficult to pull back the foreskin enough to clean thoroughly underneath. Infection with a type of virus (human papilloma virus) that causes penile warts also increases the risk of cancer of the penis.

Some skin conditions that affect the penis can go on to develop into cancer if they are left untreated. If you notice white patches, red scaly patches or red moist patches of skin on your penis, it is important to see your doctor so that you can get any treatment that you need.

Signs and symptoms

The most common symptom is a growth or sore on the penis. There may also be a discharge or bleeding. These symptoms may occur with conditions other than cancer. Like most cancers, cancer of the penis is easiest to treat if it is diagnosed early, so if you have any worries it is best to go to your doctor straight away.

How it is diagnosed

Your GP will examine you and may then refer you to a hospital specialist for advice and treatment.

The specialist will examine the whole of the penis and the lymph nodes in your groin. If the cancer has spread to the lymph nodes they may be enlarged. To make a firm diagnosis, the doctor will take a sample of tissue (a biopsy) from any sore or abnormal areas. The biopsies will be examined under a microscope.

Further tests

If the biopsy shows that you have cancer your doctor may want to do some further tests to check whether the cancer has spread. Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system is part of the body’s defence against infection and disease. The system is made up of a network of lymph glands (also known as lymph nodes) that are linked by fine ducts containing lymph fluid. The results of these tests will help the specialist to decide on the best type of treatment for you.

Chest x-ray  A chest x-ray is usually done to check whether the cancer has spread to the lungs.

CT (computerised tomography) scan  A CT scan is a specialised type of x-ray. A series of pictures is taken and fed into a computer to build up a detailed picture of the inside of the body. The scan can show whether the cancer has spread to other parts of the body. It is painless and takes 10–30 minutes.

Lymph node biopsy  If you have any enlarged lymph nodes in the groin, your doctor may put a needle into the node to get a sample of cells. This is to see whether the enlargement is due to cancer. Enlarged lymph nodes are often due to infection and not cancer, so your doctor may also give you a course of antibiotics to see whether the swollen nodes shrink.

Staging

The ‘stage’ of a cancer is a term used to describe its size and whether it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment.

• Stage 1  The cancer only affects the skin covering the penis, the head of the penis (glans) or the foreskin.
• Stage 2  The cancer has begun to spread into the shaft of the penis or into one of the lymph nodes in the groin.
• Stage 3  The cancer has spread deep into the shaft of the penis or to many lymph nodes in the groin.
• Stage 4  The cancer has spread to lymph nodes deep in the groin, or to other parts of the body.

If the cancer comes back after initial treatment, this is known as recurrent cancer.

Grading

Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how quickly the cancer may develop. Low-grade means that the cancer cells look very like normal cells; they are usually slow-growing and are less likely to spread. In high-grade tumours the cells look very abnormal, are likely to grow more quickly and are more likely to spread.

Treatment

The type of treatment that you are given will depend on a number of things, including the position and size of the cancer, whether it has spread, the grade of the cancer and your general health.

The treatments used for penile cancer include surgery, radiotherapy and chemotherapy. Surgical techniques have advanced recently and it is usually possible to either preserve the penis or perform a reconstruction. 

Men with cancer of the penis should be treated in a specialist cancer centre.

Surgery

Small, surface cancers that have not spread are treated by removing only the affected area. The cancer can be removed with conventional surgery, using laser or by freezing (cryotherapy). Cryotherapy is carried out with a cold probe, which freezes and kills the cancer cells.

If the cancer is affecting only the foreskin, it may be possible to treat it with circumcision alone.

All the above treatments can usually be given as an outpatient. They may be done under local or general anaesthetic, depending on individual circumstances.

Wide local excision  If the cancer has spread over a wider area you will need to have an operation known as a wide local excision. This means removing the cancer with a border of healthy tissue around it. This border of healthy tissue is important as it reduces the risk of the cancer coming back in the future. The operation is done under general anaesthetic and will involve a short stay in hospital.

Removing the penis (penectomy)  This may be advised if the cancer is large and is covering a large area of the penis. Amputation may be partial (where part of the penis is removed) or total (removal of the whole penis). The operation most suitable for you depends on the position of the tumour. If the tumour is near the base of the penis, total amputation may be the only option.

The surgeon may also remove lymph nodes from the groin if there is a possibility that cancer cells have spread to these nodes.

Reconstructive surgery  It is often possible to have a penis reconstructed after amputation. This requires another operation. The techniques that may be used include taking skin and muscle from your arm and using this to make a new penis. Sometimes it is also possible for surgeons to reconnect some of the nerves to provide sensation and the necessary blood flow to allow the reconstructed penis to become erect. Surgeons who do this type of surgery have specialist experience and you may need to travel to a specialist hospital to have the surgery done.

Radiotherapy

External radiotherapy is normally given as a series of short daily treatments in the hospital’s radiotherapy department. High-energy x-rays are directed from a machine at the area of the cancer. The treatments are usually given from Monday to Friday, with a rest at the weekend. Each treatment takes 10–15 minutes. The number of treatments will depend on the type and size of the cancer but the whole course of treatment for early cancer will usually last up to 6 weeks. Your doctor will discuss the treatment and possible side effects with you.

Before each session of radiotherapy the radiographer will position you carefully on the couch and make sure that you are comfortable. During your treatment you will be left alone in the room, but you will be able to talk to the radiographer who will be watching you carefully from the next room.

Radiotherapy is not painful but you do have to lie still for a few minutes while your treatment is being given. The treatment will not make you radioactive and it is perfectly safe for you to be with other people, including children, after your treatment.

Radioactive implants  Radiotherapy can be given using a radioactive implant. This is also known as brachytherapy. Under a general anaesthetic, small radioactive wires are very carefully positioned in the affected area of the penis. The wires stay in place for about 4–5 days and are then removed. This method of treatment is usually used for smaller cancers on the end of the penis (the glans). While the implant is in place you need to stay in an isolated room in the hospital so that other people are not exposed unnecessarily to the radiation.

Side effects of radiotherapy

There are sometimes side effects from radiotherapy treatment to the penis. Towards the end of your treatment, the skin on your penis can become sore and may breakdown. Long-term, radiotherapy can cause thickening and stiffening of healthy tissues (known as fibrosis). In some men, this can result in narrowing of the tube that carries urine through the penis (the urethra) and so can cause difficulty in passing urine. If narrowing of the urethra does develop it can usually be relieved by an operation to stretch (dilate) the area. This is done by passing a tube into the urethra and is performed under a general anaesthetic.

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It can be one drug or several drugs used together. It is not commonly used to treat cancer of the penis. Chemotherapy cream may sometimes be used to treat very small, early cancers that are confined to the foreskin and end of the penis (glans).

Chemotherapy may also be given as tablets or by injection into a vein for more advanced cancer. It may be given along with surgery or radiotherapy (or both). This treatment is still experimental and is given as part of research trials (clinical trials).

Clinical trials

Research into new ways of treating cancer of the penis is going on all the time. Cancer doctors use clinical trials to assess new treatments.

Your doctor must discuss the treatment with you so that you have full understanding of the trial and what it means to take part.

CancerBACUP has a section that explains how clinical trials are set up and answers some of the most common questions.

Follow-up

After your treatment is completed, you will have regular check-ups and possibly scans or x-rays. These will probably continue for several years. If you have any problems, or notice any new symptoms between these times, let your doctor know as soon as possible.

For people whose treatment is over apart from regular check-ups, CancerBACUP’s section on adjusting to life after cancer gives useful advice.

Support

The need for practical and emotional support will, of course, be individual and may depend on the treatment you receive and any side effects that the treatment may cause. For example, some surgery or radiotherapy may affect your ability to have an erection and to pass urine normally. Before you agree to treatment your specialist will inform you of any potential side effects and how to deal with them.

CancerBACUP has a section on sexuality and cancer which discusses how cancer of the penis and its treatments may affect you sexually.

Your feelings

Many different emotions may affect you. Anger, guilt, anxiety and fear are some of the most common feelings that people have. You may find yourself tearful, restless and unable to sleep. You may have feelings of hopelessness and depression. These are all normal reactions, but it is often difficult and distressing to admit to them.

You do not have to cope with these feelings on your own; there are people available to help you. Some hospitals have their own emotional-support services with specially trained staff, and some of the nurses on the ward will have received training in counselling. You may feel more comfortable talking to a counsellor outside the hospital environment or to a religious leader.

CancerBACUP can put you in touch with counselling services in your area and also a section which discusses how to deal with the emotional effects of cancer.

References

This section has been compiled using information from a number of reliable sources including;

• Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University Press, 2002.
• Cancer and Its Management (4th edition). Souhami and Tobias. Oxford Blackwell Scientific Publications, 2003.
• The Textbook of Uncommon Cancers (2nd edition). Raghavan et al. Wiley, 1999.

For further references, please see the general bibliography.