MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas, MD Anderson Cancer Center. Cancer Newsline helps you stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin, and today our guest is Dr. Lance Pagliaro, he is a professor of genitourinary medical oncology here at MD Anderson and we're going to be talking about a very rare male cancer, penile cancer or cancer of the penis. Dr. Pagliaro, extremely rare, like less than 5,000 Americans a year, correct?
Dr. Lance Pagliaro: Less than 2,000 Americans per year. It's less than 1 percent of cancers in the United States. There are parts of the world where it is more common and it has been estimated there are about 26,000 new cases per year worldwide.
Lisa Garvin: It must be a devastating diagnosis to any man, I'm sure.
Dr. Lance Pagliaro: It is. It's a very serious cancer, it's one of the cancers that we call squamous cell carcinoma, which if you look at all types of squamous cell carcinoma, that is perhaps the most common type of cancers, most skin cancer is squamous cell carcinoma, although penile cancer is not simply skin cancer on the penis, it's a different, it's a different disease.
Lisa Garvin: What are the risk factors? I mean is this a sporadic disease or are there certain defined risk factors for penile cancer?
Dr. Lance Pagliaro: There are several defined risk factors. [Pause] One of them is lack of circumcision. Penile cancer is rare among males who were circumcised at birth. Circumcision later in life does not appear to be protective. Also a condition called phimosis, which is where the foreskin cannot be retracted due to chronic inflammation and scarring. Also cigarette smoking and infection with the human papilloma virus, HPV, appears to be related to approximately 40 percent of cases, but not all cases of penile cancer.
Lisa Garvin: Do we know what strains of HPV?
Dr. Lance Pagliaro: That's been looked at, yes. The, there are two, what we call oncogenic strains, that are implicated in many human cancers, those are HPV 16 and HPV 18, and in studies of penile cancer, the strain that is identified most often is HPV 16.
Lisa Garvin: But when we compare men who get HPV to men that get penile cancer, there's still quite a divergence between those who have HPV and those who get penile cancer?
Dr. Lance Pagliaro: Right. There are dozens of strains of HPV, and as I said, not all of them are oncogenic. And many, many men and women throughout the world [pause] are infected with HPV at different points in their life. The infection is not something that's carried around permanently, it can be cleared and then people can be exposed to reinfection. And certainly there are many, many individuals who have been exposed to HPV and never develop cancer from it, so it is one factor in the development of this particular cancer in, as I said, about 40 percent of patients, but it's certainly not sufficient by itself.
Lisa Garvin: Is there any connection between penile cancer and risky sexual lifestyles?
Dr. Lance Pagliaro: [Pause] Well, that's a difficult question to answer. I guess I'd have to say I don't know. There [pause] is an association with HPV, and that is a sexually transmitted disease. There is association with HIV, although most penile cancer patients do not have HIV. Beyond that, no I, I think one would have to extrapolate from other sources of data, and [pause] I guess it would depend on what you mean by risky lifestyle.
Lisa Garvin: What are the symptoms, what would a man typically start to see and do symptoms show up at an early stage?
Dr. Lance Pagliaro: Typically it occurs near the end of the penis, on the head of the penis around the foreskin. It can be detected at a small size. It may be either a flat, sort of ulceration on the skin or it may be a growth or a lump that sort of rises from the surface of the skin. Now that may be obvious if it's on the outside of the foreskin or near the tip of the penis. It may be not recognized for what it is, because it can resemble a fungal infection or other type of irritation. Or it may be missed because it's under the foreskin, particularly a foreskin that cannot be retracted, the lesion may be hidden in that sense.
Lisa Garvin: Typically at what stage do you diagnosis them? When they're actually coming in and saying, "I think something's wrong."?
Dr. Lance Pagliaro: Right. Well most of them would be diagnosed at that stage where the lesion is confined to the penis and those can be treated very successfully in terms of survival. Amputation of the penis or, or part of the penis is not always necessary. There are a number of newer surgical techniques that can preserve parts of the penis or it can even preserve the head of the penis, or if the head of the penis has to be removed, there are newer techniques for [pause] reconstructing a head of the penis from the patient's tissues. When penile cancer becomes life threatening is the later stage at which the cancer spreads through the lymph system to lymph nodes, first in the, what we call the inguinal region or the groin.
Lisa Garvin: So, surgery would be, I guess, the frontline treatment. Is there adjuvant therapy like chemotherapy, brachytherapy, radiation?
Dr. Lance Pagliaro: All of the above.
Lisa Garvin: Oh. Uh huh. So, so surgery would be the first and then when, do all men get radiation or?
Dr. Lance Pagliaro: No. [Pause] It's an alternative to surgery for some small tumors. It can be used to get together with surgery, you know, before or after surgery or in some cases instead of surgery for management of or control of cancer in the lymph nodes. [Pause] So there is no setting where radiation is sort of the first choice standard.
Lisa Garvin: And would you do brachytherapy on penile cancers? I know it's done for prostate.
Dr. Lance Pagliaro: Brachytherapy for penile cancer is a specialty area where they actually insert rods right through the penis and the radioactive goes through those rods. I don't know much about it to speak technically about it, but that is a technique that's been studied and described, but in any case that that is done, one could also do conventional radiation or surgery. So it's always a [pause] an option among several options.
Lisa Garvin: Because it's so rare, at least here in the United States, is there like a paucity of data in maybe tumor samples that may hinder your study of better cures?
Dr. Lance Pagliaro: Always. And the, you know, most obvious deficit that we have for penile cancer is there are no randomized clinical trials, which is always the first thing we consider for [pause] deciding how to treat other types of cancer.
Lisa Garvin: Is there, are there new treatments on the horizon? Obviously minimally invasive surgery and robotics, I mean, I don't know if these are used for penile cancer, but it seems like advances in surgery may help people with this disease.
Dr. Lance Pagliaro: Robotic-assisted surgery or minimally invasive surgery is being looked at in the exploration of the groin or of removing lymph nodes that are or may be containing tumor from the groin region. That's still a somewhat investigational technique.
Lisa Garvin: And what about reconstructive surgeries? We hear a lot about breast reconstruction, obviously it's a much more common cancer, but, and I know you're not a reconstructive surgeon, but what sort of reconstructive surgery options are out there? I mean with breasts, sometimes they're taking tissue from different parts of the body to create a new breast or they're doing implants, what sort of things are being done to reconstruct the penis?
Dr. Lance Pagliaro: Well similar. You know, skin grafts can be taken from the thigh and used to resurface areas where very shallow tumor lesions have been removed with the skin. Glans reconstruction, I mentioned that the glans is the head of the penis, there are techniques for that, and less commonly used, but possible, is reconstruction of the phallus actually creating a [pause] a new penis out of the patient's tissue and that's a much more involved procedure, not as commonly done.
Lisa Garvin: I mean we hear about lumpectomies in breast cancer as an effort to save the remaining breast tissue, do you do that in penile cancer of do you have to take a healthy margin along with the tumor, as well?
Dr. Lance Pagliaro: Well, in surgical procedure you have to take a margin, but the, our understanding of how much margin has changed over time, so that where maybe years ago it was thought you needed a 2-centimeter margin, now it's more like 2 millimeters, so we can do more conservative surgery. But, one still does have to have a margin and in some cases, postoperative treatment such as chemotherapy or radiation to prevent recurrence. A newer area that is not yet standard would be actual penis preservation where amputation or partial amputation might be standard, to instead use chemotherapy to shrink the tumor and radiation to eliminate any remaining cancer cells. That would still be considered investigational, but it's a new treatment that might be available in the future.
Lisa Garvin: So what would be your message to men who might think they have symptoms of penile cancer?
Dr. Lance Pagliaro: Oh, if, if there's any symptom that, you know, appears on the penis that you're worried about, certainly discuss it with your family doctor or your urologist. If its penile cancer, you want to get that treated right away, but it may not be penile cancer and only your urologist can really answer that question for you.
Lisa Garvin: Great. Thank you very much. If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789 [Background Music] or online at mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.
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