Penile Cancer (Cancer of the Penis)

What is cancer?

Cancer is a disease of the cells in the body. The body is made up from millions of tiny cells. There are many different types of cell in the body, and there are many different types of cancer which arise from different types of cell. What all types of cancer have in common is that the cancer cells are abnormal and multiply 'out of control'.

A malignant tumour is a 'lump' or 'growth' of tissue made up from cancer cells which continue to multiply. Malignant tumours invade into nearby tissues and organs which can cause damage.

Malignant tumours may also spread to other parts of the body. This happens if some cells break off from the first (primary) tumour and are carried in the bloodstream or lymph channels to other parts of the body. These small groups of cells may then multiply to form 'secondary' tumours (metastases) in one or more parts of the body. These secondary tumours may then grow, invade and damage nearby tissues and can spread again.

Some cancers are more serious than others, some are more easily treated than others (particularly if diagnosed at an early stage), some have a better outlook (prognosis) than others.

So, cancer is not just one condition. In each case it is important to know exactly what type of cancer has developed, how large it has become and whether it has spread. This will enable you to get reliable information on treatment options and outlook.

See separate leaflet called 'What are Cancer and Tumours' for further details about cancer in general.

What is penile cancer and what causes it?

Penile cancer is a cancer that develops on the penis. A cancerous tumour starts from one abnormal cell. The exact reason why a cell becomes cancerous is unclear. It is thought that something damages or alters certain genes in the cell. This makes the cell abnormal and multiply 'out of control'. (See separate leaflet called 'What Causes Cancer' for more details.)

In most cases, the reason why penile cancer develops is not known. However, there are factors which are known to alter the risk of penile cancer developing. These include:

• Age. Penile cancer is more common in men over the age of 50.
• Many cases of penile cancer are associated with an infection with certain types of human papillomavirus (see below).
• Some skin conditions of the foreskin are can increase the risk of having penile cancer in the future. These include a condition called erythroplasia of Queyrat and balanitis xerotica obliterans. These are both rare conditions.
• Phimosis in adults and poor hygiene around the foreskin can increase the risk of penile cancer. Phimosis is when the foreskin remains unusually tight and cannot be drawn back from the head of the penis.
• Having a circumcision as a baby or child seems to protect against penile cancer.

Human papilloma virus (HPV) and penile cancer

There are many strains of HPV. Two types, HPV 16 and 18, are involved in the development of many cases of penile cancer. (Note: some other strains of HPV cause common warts and verrucas. These strains of HPV are not associated with penile cancer.)

The strains of HPV associated with penile cancer are nearly always passed on by having sex with an infected person. An infection with one of these strains of HPV does not usually cause symptoms. So, you cannot tell if you or the person you have sex with are infected with one of these strains of HPV.

In some men, the strains of HPV that are associated with penile cancer seem to affect the cells of the penis. This makes them more likely to become abnormal which may later (usually many years later) turn into cancerous cells. Note: within two years, 9 out of 10 infections with HPV will clear completely from the body. This means that most men who are infected with these strains of HPV will never develop cancer.

How common is penile cancer?

Penile cancer is rare in the UK. There are only around 360 new cases each year in the UK. However, in some areas of Asia, Africa and South America it is more common.

What are the symptoms of penile cancer?

Almost all penile cancers first develop on the glans (head) of the penis or on the underside skin of the foreskin (if you are not circumcised). It is rare to develop penile cancer on the main shaft of the penis. Therefore, you may only notice an early cancer if you pull back your foreskin.

Typically, the first symptom is a change in colour of the skin of the affected part of the glans or foreskin of the penis. The affected skin can also become thickened or appear like a small red rash. The affected area of skin may then gradually develop into a small flat growth (often bluish-brown in colour) or a growth or sore which may bleed. It does not usually cause pain. In some cases the early cancer develops as small crusty bumps.

Left untreated, the cancer typically grows to involve the entire surface of the glans and/or foreskin. It then eventually spreads further to deeper parts of the penis and to other areas of the body to cause various other symptoms.

How is penile cancer diagnosed and assessed?

Anyone who has an abnormal growth or sore on their penis will have a thorough examination by their doctor. This will usually include feeling for any enlarged lymph glands in the groin. You will then be referred to see a specialist in the hospital.

It is likely that further tests in the hospital will be arranged. These may include:

• A biopsy. This is where a small piece of tissue is taken from the cancer and sent to the laboratory. Sometimes biopsies are also taken from the lymph glands in the groin. Results of a biopsy can take two weeks.
• An MRI of the penis may be performed to assess the size of the cancer.
• A CT scan of the chest, abdomen and pelvis may be performed. These scans can provide detail on the structure of the internal organs. (See separate leaflets called 'CT Scan' and 'MRI Scan' for more details.)

Stages of penile cancer range from stage 1 (where the cancer is confined to the skin of the penis) to stage 4 (where there is spread to lymph nodes deep in the pelvis or to other parts of the body).

Grading of the cancer cells

If a biopsy of the cancer is taken then the cells can assessed. By looking at certain features of the cells under the microscope the cancer can be 'graded'.

• Grade 1 (low grade) - the cells look reasonably similar to normal cells. The cancer cells are said to be 'well differentiated'. The cancer cells tend to grow and multiply quite slowly and are not so 'aggressive'.
• Grade 2 - is a middle grade.
• Grade 3 - the cells look very abnormal and are said to be 'poorly differentiated'. The cancer cells tend to grow and multiply quite quickly and are more 'aggressive'.

Finding out the stage and grade of the cancer helps doctors to advise on the best treatment options. It also gives a reasonable indication of prognosis (outlook).

See separate leaflet called 'Cancer Staging and Grading' for more details.

What are the treatment options for penile cancer?

Treatment options may include surgery, chemotherapy and radiotherapy. The treatment advised for each case depends on various factors such as the stage and grade of the cancer, and your general health. A specialist will be able to give the pros and cons, likely success rate, possible side-effects and other details about the various possible treatment options for your type and stage of cancer.

You should also discuss with your specialist the aims of treatment. For example:

• In some cases, treatment aims to cure the cancer. (Doctors tend to use the word 'remission' rather than the word 'cured'. Remission means there is no sign of cancer following treatment. If you are 'in remission', you may be cured. However, in some cases a cancer returns months or years later. This is why doctors are sometimes reluctant to use the word cured.)
• In some cases, treatment aims to control the cancer. If a cure is not realistic, with treatment it is often possible to limit the growth or spread of the cancer so that it progresses less rapidly. This may keep you free of symptoms for some time.
• In some cases, treatment aims to ease symptoms. For example, if a cancer is advanced then you may require treatments such as painkillers or other treatments to help keep you free of pain or other symptoms. Some treatments may be used to reduce the size of a cancer which may ease symptoms such as pain.

Surgery

An operation is advised in most cases. The type of operation depends upon the size of the cancer and its position on the penis. If the cancer is small and only on the skin of the penis then the cancer and a small amount of normal tissue can be removed. However, if the cancer is larger then either part of the penis or even the entire penis is removed.

Reconstructive surgery is an option for many men. Your surgeon will be able to discuss the different types of reconstructive surgery with you in more detail. The lymph glands in the groin are often also removed during the operation.

Chemotherapy

Chemotherapy is a treatment of cancer by using anti-cancer drugs which kill cancer cells or stop them from multiplying. See separate leaflet called 'Chemotherapy with Cytotoxic Drugs' for more details. Chemotherapy may be given after having an operation. This aims to kill any cancer cells that have been left behind following the operation.

Sometimes chemotherapy is given before surgery to reduce the size of the cancer. This may make surgery easier and more likely to be successful.

Radiotherapy

Radiotherapy is a treatment that uses high energy beams of radiation which are focused on cancerous tissue. This kills cancer cells or stops cancer cells from multiplying. (See separate leaflet called 'Radiotherapy' for more details.) Radiotherapy is sometimes used for smaller cancers in people who do not need an operation. This is less common though.

Other treatments

If the cancer is at an early stage and is only on the glans (the head of the penis), sometimes doctors prescribe a cytotoxic (cell-killing) cream that can be used on the cancer.

What is the prognosis (outlook)?

There is a good chance of a cure if penile cancer is diagnosed and treated when it is at an early stage (confined to the penis and has not spread to the lymph glands). In general, the later the stage and the higher the grade of the cancer, the poorer the outlook. Even if a cure is not possible, treatment can often slow down the progression of the cancer.

The treatment of cancer is a developing area of medicine. New treatments continue to be developed and the information about outlook given above is very general. The specialist who knows your case can give more accurate information about your particular outlook, and how well your stage and grade of cancer is likely to respond to treatment.

Most treatments for penile cancer will not affect your ability to have sex, even if you need an operation.

Further help and information

Macmillan Cancer Support

Tel: 0808 800 1234 Web: www.macmillan.org.uk
Provide information and support to anyone affected by cancer.

Cancer Research UK

Their website www.cancerhelp.org.uk provides facts about cancers and their treatment.

British Urological Foundation

Web: www.buf.org.uk
They have comprehensive leaflets for patients, including one on cancer of the penis.

Other support groups

See www.patient.co.uk/selfhelp.asp for a list of self help and support groups for cancer.