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Penile Cancer
Penile Cancer
When a man gets an erection, nerves signal his body to store blood in the vessels inside
the corpora cavernosa. As the blood fills the chambers, the spongy tissue expands,
causing the penis to elongate and stiffen. During ejaculation, semen (which contains
sperm cells and fluids) enters the urethra and passes out of the body through the meatus.
After ejaculation, the blood flows back into the body, and the penis becomes soft again.
Bowenoid papulosis
This condition is also linked to infection with HPV and tends to occur in younger,
sexually active men. It is seen as small, red or brown spots or patches on the shaft of the
penis. These often look like genital warts, but when looked at under a microscope,
dysplastic (abnormal) cells are seen in the surface layer of the penile skin.
Bowenoid papulosis can also be mistaken for an early-stage cancer called carcinoma in
situ (CIS), also known as Bowen disease (described below). Usually bowenoid papulosis
doesn’t cause any problems, and it can even go away on its own after a few months. But
if it doesn’t go away and is not treated, rarely it can progress to Bowen disease.
Melanoma
Melanoma is a type of skin cancer that starts in melanocytes, the cells that make the
brownish color in the skin that helps protect it from the sun. These cancers tend to grow
and spread quickly and are more dangerous than the more common types of skin cancer.
Melanomas are most often found in sun-exposed skin, but rarely they occur in other areas
like the penis. Only a very small portion of penile cancers are melanomas. For more
information about melanoma and its treatment, see Melanoma Skin Cancer.
Sarcoma
A small number of penile cancers are sarcomas. These cancers develop from blood
vessels, smooth muscle, or other connective tissue cells of the penis. For more about this
type of cancer, see Sarcoma - Adult Soft Tissue Cancer.
What are the key statistics about penile
cancer?
The American Cancer Society estimates for penile cancer in the United States for 2016
are:
• About 2,030 new cases of penile cancer diagnosed
• About 340 deaths from penile cancer
For statistics related to survival, see Survival rates for penile cancer.
Penile cancer is rare in North America and Europe. It occurs in less than 1 man in
100,000 and accounts for less than 1% of cancers in men in the United States. Penile
cancer is, however, much more common in some parts of Asia, Africa, and South
America. Visit the American Cancer Society’s Cancer Statistics Center for more key
statistics.
Smegma
Sometimes secretions can build up underneath an intact foreskin. If the area under the
foreskin isn’t cleaned well, these secretions build up enough to become a thick,
sometimes smelly substance called smegma. Smegma is more common in men with
phimosis, but can occur in anyone with a foreskin, if the foreskin is not retracted
regularly to clean the head of the penis.
In the past some experts were concerned that smegma might contain compounds that can
cause cancer. Most experts now believe that smegma itself probably doesn’t cause penile
cancer, but it can irritate and inflame the penis, which can increase the risk of cancer. It
may also make it harder to see very early cancers.
Smoking
Men who smoke are more likely to develop penile cancer. Smokers who have HPV
infections have an even higher risk. Smoking exposes your body to many cancer-causing
chemicals. These harmful substances are inhaled into the lungs, where they are absorbed
into the blood. They can travel in the bloodstream throughout the body to cause cancer in
many different areas. Researchers believe that these substances damage genes in cells of
the penis, which can lead to penile cancer. Smoking also increases the risk of HPV
infection, probably due to its effects on immune function.
Age
The risk of penile cancer goes up with age. The average age of a man when diagnosed is
68, and about 4 out of 5 penile cancers are diagnosed in men over age 55.
AIDS
Men with AIDS have a higher risk of penile cancer. This higher risk seems to be related
to their weakened immune system, which is a result of this disease. But it might also be
linked to other risk factors that men with HIV (the virus that causes AIDS) are more
likely to have. For example, men with HIV are more likely to smoke and to be infected
with HPV.
Genital hygiene
Perhaps the most important factor in preventing penile cancer in uncircumcised men is
good genital hygiene. Uncircumcised men need to pull back (retract) the foreskin and
clean the entire penis. If the foreskin is constricted and difficult to retract (a condition
called phimosis), a doctor may be able to prescribe a cream or ointment that can make it
easier to do so. If this doesn’t work the doctor may cut the skin of the foreskin in a
procedure called a dorsal slit to make retraction easier.
Not smoking
Smoking also increases penile cancer risk, so not smoking might lower that risk. Quitting
smoking or never starting in the first place is a good way to reduce your risk of many
diseases, including penile cancer.
Skin changes
Most often, the first sign of penile cancer is a change in the skin of the penis. This is most
likely to be on the glans (tip) of the penis or on the foreskin (in uncircumcised men), but
it can also be on the shaft. Possible signs of penile cancer include:
• An area of skin becoming thicker and/or changing color
• A lump on the penis
• An ulcer (sore) that might bleed
• A reddish, velvety rash
• Small, crusty bumps
• Flat, bluish-brown growths
• Smelly discharge (fluid) under the foreskin
Sores or lumps from penile cancer are not usually painful, but they can be in some cases.
You should see a doctor if you find any kind of new growth or other abnormality on your
penis, even if it is not painful.
Swelling
Swelling at the end of the penis, especially when the foreskin is constricted, is another
possible sign of penile cancer.
Lumps under the skin in the groin area
If the cancer spreads from the penis, it most often travels first to lymph nodes in the
groin. This can make those lymph nodes swell. Lymph nodes are collections of immune
system cells. Normally, they are bean-sized and can barely be felt at all. If they are
swollen, the lymph nodes may be felt as lumps under the skin.
But swollen lymph nodes don’t always mean that cancer has spread there. More
commonly, lymph nodes swell in response to an infection. The skin in and around a
penile cancer can often become infected, which might cause the nearby lymph nodes to
swell, even if the cancer hasn’t reached them.
Biopsy
A biopsy is needed to diagnose penile cancer. In this procedure, a small piece of tissue
from the abnormal area is removed and sent to a lab, where it is looked at under a
microscope to see if it contains cancer cells. The results are usually available in a few
days, but may take longer in some cases.
The type of biopsy used depends on the nature of the abnormality.
Incisional biopsy
For an incisional biopsy only a part of the abnormal area is removed. This type of biopsy
is often done for lesions that are larger, are ulcerated (the top layer of skin is missing or
the lesion appears as a sore), or that appear to grow deeply into the penis.
These biopsies are usually done with local anesthesia (numbing medicine) in a doctor’s
office, clinic, or outpatient surgical center.
Excisional biopsy
In an excisional biopsy, the entire lesion is removed. This type of biopsy is more often
used if the abnormal area is small, such as a nodule (lump) or plaque (raised, flat area). If
the abnormal area is only on the foreskin, your doctor might recommend circumcision
(removal of the foreskin) as a form of excisional biopsy.
These biopsies are usually done in a hospital or outpatient surgical center. Local
anesthesia (numbing medicine) or general anesthesia (where you are asleep) may be used.
Ultrasound
This test uses sound waves to make pictures of internal organs or masses. It can be useful
for determining how deeply the cancer has penetrated into the penis. It can also show
enlarged lymph nodes in the groin.
For this test, a small microphone-like instrument called a transducer gives off sound
waves and picks up the echoes as they bounce off body tissues. The echoes are converted
by a computer into an image on a computer screen.
This test is painless and does not expose you to radiation. For most ultrasound exams, the
skin is first lubricated with gel. Then a technician moves the transducer over the skin
above the part of your body being examined.
T categories
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ (cancer that is only in the top layers of skin). This is sometimes
called erythroplasia of Queyrat when it occurs on the glans of the penis. It can be called
Bowen disease when it occurs on the shaft of the penis.
Ta: Verrucous (wart-like) carcinoma that is only in the top layers of skin (non-invasive)
T1: The tumor has grown into the tissue below the top layers of skin (called the
subepithelial connective tissue)
• T1a: The tumor has grown into the subepithelial connective tissue, but it has not
grown into blood or lymph vessels. The cancer is grade 1 or 2.
• T1b: The tumor has grown into the subepithelial connective tissue and has either
grown into blood and lymph vessels OR it is high-grade (grade 3 or 4).
T2: The tumor has grown into at least one of the internal chambers of the penis (the
corpus spongiosum or corpora cavernosum)
T3: The tumor has grown into the urethra (the tube that carries urine and semen outside
of the body)
T4: The tumor has grown into the prostate or other nearby structures
N categories
NX: Nearby lymph nodes cannot be assessed
N0: The cancer has not spread to nearby lymph nodes
N1: The cancer has spread to a single lymph node in the groin (called an inguinal lymph
node)
N2: The cancer has spread to more than 1 inguinal lymph node
N3: The cancer has spread to lymph nodes in the pelvis and/or the cancer in the lymph
nodes has grown through the outer covering of the lymph node and into the surrounding
tissue
M categories
M0: The cancer has not spread to distant organs or tissues
M1: The cancer has spread to distant organs or tissues (such as lymph nodes outside of
the pelvis, lungs, or liver)
Stage grouping
Once the T, N, and M categories have been assigned, this information is combined to
assign an overall stage from 0 to IV. This is known as stage grouping.
Simple excision
In this operation, the tumor is cut out with a surgical knife, along with some surrounding
normal skin. If the tumor is small, the remaining skin can then be stitched back together.
This is the same as an excisional biopsy.
In a wide local excision, the cancer is removed along with a large amount of normal
tissue around it (called wide margins). Removing this healthy tissue makes it less likely
that any cancer cells are left behind. If not enough skin remains to cover the area, a skin
graft may be taken from another part of the body and placed over the area.
Brachytherapy
For brachytherapy, a radioactive source is placed into or right next to the penile tumor.
The radiation travels only a short distance, so nearby healthy tissues don’t get much
radiation. This type of treatment is done while you are in the hospital. There are 2 ways
to get brachytherapy for penile cancer.
Interstitial radiation: In this method, hollow needles are first placed into the penis in the
operating room. Then tiny pellets of radioactive materials are put into the needles to treat
the tumor. The pellets are kept in place for several days while they release radiation.
After the treatment is over, the needles are removed.
Plesiobrachytherapy: This type of brachytherapy puts the radiation source close to (but
not into) the tumor. In this method, a plastic cylinder is placed around the penis, and then
another cylinder with a radiation source is placed on top of the first cylinder. Another
way to do this is to make a sponge-like mold of the penis and put the radioactive material
into hollowed-out spaces in the mold. Treatment is usually given for several days in a
row.
Laser ablation
In this approach, the doctor uses a beam of laser light to destroy (ablate) cancer cells.
This can be useful for squamous cell carcinoma in situ (CIS) and for very thin or shallow
basal cell carcinomas.
Cryosurgery
For this approach, the doctor uses liquid nitrogen to freeze and kill the cancer cells. This
is useful for some verrucous penile cancers and carcinoma in situ (CIS) of the glans.
This is often repeated a couple of times in the same office visit. After the dead area of
skin thaws, it will swell, blister and crust over. The wound may have fluid draining from
it for a while and take a month or two to heal. It can leave a scar.
Topical chemotherapy
Topical chemotherapy means that an anti-cancer medicine is put directly onto the skin
instead of being taken as a pill or injected into a vein. The drug used most often to treat
penile cancer topically is 5-fluorouracil (5-FU), which is applied daily as a cream for
several weeks.
When put directly on the skin, 5-FU reaches cancer cells in the top layers of skin, but it
cannot reach cancer cells that have grown deeply into the skin or spread to other organs.
For this reason, treatment with 5-FU generally is used only for pre-cancerous conditions
or carcinoma in situ (CIS).
Because the drug does not spread throughout the body, the side effects that often occur
with systemic chemotherapy do not occur with topical chemotherapy. Treatment with 5-
FU cream makes the treated skin red and very sensitive for a few weeks. Using other
topical medicines or creams can help relieve this.
Imiquimod
Imiquimod is a drug that is sometimes used as a cream to treat CIS of the penis. It causes
the immune system to react to the skin lesion and destroy it. It is typically applied at least
a few times a week for several weeks, although schedules can vary. It can irritate the
skin, which can severe in some people. It can also cause flu-like symptoms, although this
is not common.
Stage 0
Stage 0 includes 2 types of tumors: carcinoma in situ (CIS) and verrucous carcinoma.
Both of these tumors are only in the top layers of skin, but they have some different
treatment options.
Patients with CIS that is only in the foreskin can often be treated with circumcision. If the
tumor is in the glans and does not affect other tissues, it may be possible to treat it with
some type of local therapy (such as laser ablation, topical 5-FU or imiquimod, or
cryotherapy). Other options might include some type of surgery, such as Mohs surgery or
wide excision. Radiation therapy might also be a possible option. Partial penectomy
(removal of part of the penis) is usually not needed.
Verrucous carcinoma can often be treated with laser therapy, Mohs surgery, wide
excision, or cryotherapy. Only rarely will a partial penectomy be needed. Radiation is not
used for this type of tumor, because it can make it more likely to spread.
Stage I
These tumors have grown below the skin of the penis but not into deeper layers.
Options for treatment may include circumcision (for tumors confined to the foreskin) or a
more extensive surgery (Mohs surgery, wide excision, or removal of part of the penis
[partial penectomy]), or radiation therapy. Laser ablation may also be an option.
Stage II
Stage II penile cancer includes tumors that have grown deep into the tissues of the penis
(such as the corpus spongiosum or cavernosum) or the urethra, but have not spread to
nearby lymph nodes.
These cancers are usually treated with a partial or total penectomy, with or without
radiation therapy. A less common approach is to use radiation therapy as the first
treatment with surgery remaining as an option if the cancer is not destroyed completely
by the radiation. Radiation may also be used as the main treatment in men who can’t have
surgery because of other health problems.
Some doctors recommend checking groin lymph nodes for cancer, even if they are not
enlarged. This may be done with a sentinel lymph node biopsy or with a more extensive
lymph node dissection. If the lymph nodes show cancer spread, then the cancer is not
really a stage II. It is a stage III or IV (and is treated as such).
Stage III
Stage III penile cancers have reached nearby lymph nodes in the groin. The main tumor
may have grown into the deeper tissues of the penis (the corpus spongiosum or corpus
cavernosum) or urethra, but has not grown into nearby structures like the bladder or
prostate.
Stage III cancers are treated with a partial or total penectomy. In a few cases,
chemotherapy (chemo) or chemo plus radiation may be used first to shrink the tumor so
that it can be removed more easily with surgery.
These cancers require an inguinal lymphadenectomy to remove lymph nodes in the groin.
Radiation therapy to the groin may be used as well, either after surgery or instead of
surgery in selected cases. If lymph nodes are very large, chemotherapy (with or without
radiation) might be used as well.
These cancers can be hard to cure, so men may want to consider taking part in clinical
trials of new treatments.
Stage IV
Stage IV penile cancer includes different groups of more advanced cancers.
In some stage IV cancers, the main tumor has grown into nearby tissues, like the prostate,
bladder, scrotum, or abdominal wall. Treatment typically includes surgery, which is often
a total penectomy. If the tumor is in the scrotum or parts of the abdominal wall, the
testicles and/or the scrotum may also need to be removed. A new opening can be made in
the abdomen or the perineum (space between the scrotum and anus) to allow urination. If
the tumor has grown into the prostate or bladder, these may need to be removed as well.
Chemo (sometimes with radiation) may be given before surgery (called neoadjuvant
treatment) to try to shrink the tumor and make it easier to remove. The inguinal (groin)
lymph nodes on both sides will be removed as well. This area may also be treated with
radiation after surgery (unless it was given before surgery).
Stage IV also includes cancers that have spread more extensively in the lymph nodes,
such as cancer in groin lymph nodes that has grown through the nodes and into
surrounding tissue or cancer spread to lymph nodes inside the pelvis. These cancers are
treated with surgery to remove the main tumor in the penis, such as penectomy. The
lymph nodes in both groin areas are also removed. The lymph nodes inside the pelvis will
also be removed if they are thought to contain cancer spread (if they are enlarged, for
example). After the lymph nodes are removed, those areas are often treated with radiation
to try to kill any cancer cells that may be have left behind. Chemotherapy might be part
of this treatment as well.
Penile cancer that has spread to distant organs and tissues is also considered stage IV.
These cancers can’t be removed or destroyed completely with surgery and radiation.
Treatment is aimed at keeping the cancer in check and preventing or relieving symptoms
to the best extent possible. Choices to treat the penile tumor usually include wide local
excision, penectomy, or radiation therapy. Surgery or radiation therapy (sometimes along
with chemotherapy) may also be considered to treat nearby lymph nodes. Radiation may
also be used to treat areas of cancer spread in the bones or in the brain or spinal cord.
Chemo is often used to treat cancer that has spread to other areas, like the lungs or liver.
Studies are under way to determine the value of chemotherapy combined with surgery or
radiation therapy.
Stage IV cancers are very hard to cure, so men may want to think about taking part in
clinical trials of new treatments.
Recurrent cancer
The treatment of cancer that comes back after treatment (recurrent cancer) depends on
where the cancer recurs and what treatments were used before. If penectomy was not
done before, a recurrent penile cancer may be treated with surgical removal of part or all
of the penis. Radiation therapy may also be an option. Surgery, radiation therapy, and/or
chemotherapy may also be options for some cancers that recur in the lymph nodes.
Chemo may also be helpful in treating penile cancers that come back in other parts of the
body.
These tumors can be hard to treat, so men may want to think about taking part in a
clinical trial of a newer treatment.
Follow-up care
If you have completed treatment, your doctors will still want to watch you closely. It’s
very important to go to all of your follow-up appointments. During these visits, your
doctors will ask about any problems are having and may do exams and lab tests or
imaging tests (such as CT scans) to look for signs of cancer or treatment side effects.
Almost any cancer treatment can have side effects. Some may last for a few weeks to
months, but others can last the rest of your life. This is the time for you to talk to your
cancer care team about any changes or problems you notice and any questions or
concerns you have.
After your treatment is finished, you will probably need to still see your cancer doctor for
many years. Doctor visits and exams will be more frequent at first (typically every few
months), but the time between visits can often get longer over time. Ask what kind of
follow-up schedule you can expect.
It’s also very important to keep your health insurance. Tests and doctor visits cost a lot,
and even though no one wants to think of their cancer coming back, this could happen.
Should your cancer come back, further treatment will depend on where the cancer is,
what treatments you’ve had before, and your health. For more on dealing with a
recurrence, see When Your Cancer Comes Back: Cancer Recurrence..
Effects on urination
Most men can still control the start and stop of urine flow after surgery. They are still
continent. But if the surgery removes part of the penis (partial penectomy) or the entire
penis (total penectomy), how a man urinates can be affected. In some cases, a partial
penectomy leaves enough of the penis to allow relatively normal urination. But men who
have had a total penectomy often must sit to urinate.
Effects on sexuality
If cancer of the penis is diagnosed early, treatments other than penectomy can often be
used. Conservative techniques such as circumcision, local therapy other than surgery
(laser ablation, topical chemotherapy), or Mohs surgery may have little effect on sexual
pleasure and intercourse once you have fully recovered.
Removing all or part of the penis can have a huge effect on a man’s self-image and
ability to have sexual intercourse. You and your sexual partner may wish to consider
counseling to help understand the impact of treatment for penile cancer and to explore
other approaches to sexual satisfaction.
Satisfying intercourse is possible for many, but not all men after partial penectomy. The
remaining shaft of the penis can still become erect with arousal. It usually gains enough
length to achieve penetration. Although the most sensitive area of the penis (the glans, or
“head”) is gone, a man can still reach orgasm and ejaculate normally. His partner should
also still be able to enjoy intercourse and often reach orgasm.
Normal intercourse is not possible after total penectomy. Some men give up sex after the
surgery. Since cancer of the penis is most common in elderly men, some are already
unable to have intercourse because of other health problems. If a man is willing to put
some effort into his sex life, however, pleasure is possible after total penectomy. He can
learn to reach orgasm when sensitive areas such as the scrotum, skin behind the scrotum,
and the area surrounding the surgical scars are caressed. Having a sexual fantasy or
looking at erotic pictures or stories can also increase excitement.
A man can help his partner reach orgasm by caressing the genitals, by oral sex, or by
stimulation with a sexual aid such as a vibrator. The activity some couples enjoy after
total penectomy can give hope to those coping with fewer changes in their sex lives.
After total penectomy, surgical reconstruction of the penis might be possible in some
cases. If you are interested in this, ask your doctor if this might be an option for you.
Removing all or part of the penis can also have a devastating effect on a man’s self-
image. Some men might feel stressed or depressed, or might not feel “whole” after the
operation. These are valid and understandable feelings, but they can often be helped with
counseling or talking with others. For more on this, see the section “How might having
penile cancer affect your emotional health?”
For more information on sexuality after cancer, see Sexuality for the Man with Cancer.
Lymphedema
The lymph nodes in the groin area normally help excess fluid drain out of the lower part
of the body and back into the bloodstream. If the groin lymph nodes are removed or
treated with radiation, it can sometimes lead to problems with fluid drainage in the legs or
scrotum, causing abnormal swelling. This condition is called lymphedema.
This problem was more common in the past because more lymph nodes were removed to
see if the cancer had spread. Now fewer lymph nodes are usually removed, which lowers
the risk of lymphedema. But lymphedema can still occur even with less treatment. For
more on this, see Understanding Lymphedema: For Cancers Other than Breast Cancer.
Eating better
Eating right can be hard for anyone, but it can get even tougher during and after cancer
treatment. Treatment may change your sense of taste. Nausea can be a problem. You may
not feel like eating and lose weight when you don’t want to. Or you may have gained
weight that you can’t seem to lose. All of these things can be very frustrating.
If treatment causes weight changes or eating or taste problems, do the best you can and
keep in mind that these problems usually get better over time. You might find it helps to
eat small meals every 2 to 3 hours until you feel better. You might also want to ask your
cancer team about seeing a dietitian, an expert in nutrition who can give you ideas on
how to deal with these treatment side effects.
One of the best things you can do after cancer treatment is to start healthy eating habits.
You may be surprised at the long-term benefits of some simple changes, like increasing
the variety of healthy foods you eat. Getting to and staying at a healthy weight, eating a
healthy diet, and limiting your alcohol intake may lower your risk for a number of types
of cancer, as well as having many other health benefits.
Hospice care
At some point, you may benefit from hospice care. This is special care that treats the
person rather than the disease; it focuses on quality rather than length of life. Most of the
time, it is given at home. Your cancer may be causing problems that need to be managed,
and hospice focuses on your comfort. You should know that while getting hospice care
often means the end of treatments such as chemo and radiation, it doesn't mean you can't
have treatment for the problems caused by your cancer or other health conditions. In
hospice the focus of your care is on living life as fully as possible and feeling as well as
you can at this difficult time. You can learn more in Hospice Care.
Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is
still hope for good times with family and friends, times that are filled with happiness and
meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on
the most important things in your life. Now is the time to do some things you’ve always
wanted to do and to stop doing the things you no longer want to do. Though the cancer
may be beyond your control, there are still choices you can make.
You can learn more about the changes that occur when curative treatment stops working,
and about planning ahead for yourself and your family, in Nearing the End of Life and
Advance Directives.