Cancer of the penis (penile cancer)
Cancer of the penis is rare in Europe and the USA, but more common in South East Asia, parts of Africa, and India. Approximately 400 men are diagnosed with this type of cancer in the UK each year. It is most often diagnosed in men over the age of 60 years.
Causes
The exact cause of cancer of the penis is unknown. It is thought to be related to general hygiene and is much less common in men who have had all or part of their foreskin removed (been circumcised) 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. The human papilloma virus (HPV) 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.
Cancer of the penis is not infectious and cannot be passed on to other people. It is not caused by an inherited faulty gene and so other members of your family are not likely to develop it.
Signs and symptoms
The first signs of a penile cancer are often a change in colour of the skin and skin thickening. Later symptoms include a growth or sore on the penis, especially on the glans (head of the penis) or foreskin, but also sometimes on the shaft of the penis. There may be a discharge or bleeding. Most penile cancers are painless.
Sometimes the cancers appear as flat growths that are bluish-brown in colour, or as a red rash, or small crusty bumps. Often the cancers are only visible when the foreskin is pulled back.
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 on the penis. This will usually be done under a local anaesthetic so that the area is numb. 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 or not 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 or not 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 or not 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 or not 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 or not the swollen nodes shrink.
Staging and grading
Staging
The stage of a cancer is a term used to describe its size and whether or not it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the best treatment for you.
- 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 pelvis, or to other parts of the body.
If your 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 or not 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 to you 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 evidence that cancer cells have spread to these nodes, or a possibility that they may have.
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. This type of surgery is carried out by surgeons who have specialist experience, and you may need to travel to a specialist hospital to have the surgery done.
Radiotherapy
Radiotherapy treats cancer using high-energy rays to destroy cancer cells, while doing as little harm as possible to healthy cells. It can be used before or after surgery. Radiotherapy may also be given to treat symptoms, such as pain, if the cancer has spread to other parts of the body, like the bones.
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 for up to six 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 break down. Long-term, radiotherapy can cause thickening and stiffening of healthy tissues (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).
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. Before any trial is allowed to take place, an ethics committee must have approved it, and agreed that it is in the interest of the patients.
You may be asked to take part in a clinical trial. Your doctor must discuss the treatment with you so that you have full understanding of the trial and what it involves. You may then decide not to take part, or withdraw from the trial, at any stage. You will then receive the best standard treatment available.
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.
Your feelings and 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.
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.
Sex after penile cancer
You may worry that you will never be able to have sex again. However, most treatment for penile cancer will not affect your ability to have sex. But, some men who have had part of their penis removed, and those who have had the whole penis removed, will find that their sex life is affected. This can be very distressing and may take time to come to terms with.
It can help to talk to your partner about how you are feeling, and about the changes in your relationship. This can be very difficult and you may need to get help from a specialist nurse or counsellor. They can help you, and your partner, to deal with these changes. Your GP, hospital doctor, or one of our cancer support service nurses can usually put you in touch with a counsellor or specialist nurse.
