Causes and risk factors
The exact cause of penis cancer is unknown. It seems to be less common in men who have had all or part of their foreskin removed (been circumcised) soon after birth. This might be 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 penis cancer.
The penis and their surrounding structures
Some skin conditions that affect the penis may go on to develop into cancer if they are left untreated. It's important to see your doctor if you notice white patches, red scaly patches, or red moist patches of skin on your penis.
Cancer of the penis isn't infectious and can't be passed on to other people. Currently, doctors don’t think it is caused by an inherited faulty gene and so other members of your family don't have an increased risk of developing it.
Signs and symptoms
The first signs of penis cancer are often a change in color of the skin, or skin thickening. Later signs may include a growth or sore on the penis - especially on the head of the penis (glans) or the 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, bluish-brown growths, or as a red rash, or small crusty bumps. Often the cancers are only visible when the foreskin is pulled back.
These changes may occur with conditions other than cancer. Penis cancer is easier to treat if it's diagnosed early, so if you have any worries it’s best to go to your doctor straight away.
How it is diagnosed
Your PCP will examine you and refer you to a hospital specialist for expert advice and treatment.
The specialist will examine the whole of the penis and your groin to feel for any swellings. To make a firm diagnosis, the specialist may take a sample of tissue (a biopsy) from any sore or abnormal areas on the penis. This will be done under an anesthetic (local or general) so that the procedure is painless. The biopsies will be examined under a microscope by a pathologist (a doctor who specializes in examining tissue).
If the biopsy shows that you have cancer of the penis, your doctor will refer you to a specialist center. This may be some distance from your home and local hospital.
The doctors at the center will often do some extra tests to check whether the cancer has spread. The results of these tests will help the specialist to decide on the best type of treatment for you.
CT (computerized tomography) scan
A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10-15 minutes. CT scans use a small amount of radiation, which would be very unlikely to harm you or anyone you come into contact with. You'll be asked to not eat or drink for at least four hours before the scan.
You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. This may make you feel hot all over for a few minutes. It’s important to let your doctor know if you are allergic to iodine or have asthma, because you could have a more serious reaction to the injection.
Lymph node biopsy
Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system is part of the body's defense against infection and disease. The system is made up of a network of lymph nodes (also known as lymph glands), which are linked by fine ducts containing lymph fluid.
If the cancer has spread to the lymph nodes in your groin, they may be enlarged. However, these glands may also become enlarged because of infection. 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 (biopsy). This is to see whether or not the enlargement is due to cancer.
Even if the glands in your groin are not enlarged, your doctor may still want to do a biopsy. This will usually happen if the information from other tests shows that there’s a high chance the cancer might have spread at a microscopic level. In these situations, the biopsy will involve removal of one or more lymph nodes. A pathologist will examine the nodes for traces of cancer.
There are two ways of doing this type of biopsy:
This procedure is also called an inguinal lymph node dissection. During this operation the surgeon will remove a selection of lymph nodes from one or both sides of the groin.
Sentinel lymph node biopsy
During this procedure, the surgeon injects a mixture of a blue dye and a weak radioactive substance into the area of the biopsy. The mixture flows along the same lymphatic channels that cancer cells are likely to spread. It is absorbed by the first lymph node that the cancer cells are most likely to spread from the primary cancer in the penis. With the help of a scanner, the surgeon can then identify the affected lymph node and remove it. Your doctor can give you more detailed information about this procedure.
Staging and grading
The stage of a cancer is a term used to describe its size and how far it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors decide on the most appropriate treatment for you.
The most commonly used staging system is called the TNM system:
- Trefers to the size or position of the primary tumor (where the cancer first starts in the body).
- Nrefers to which lymph nodes are affected, if any.
- Mrefers to metastatic disease (when the cancer has spread to other parts of the body).
The T, N and M will often have numbers attached to describe the detail. For example, a T1 tumor may be very small and just in one layer of tissue, whereas a T4 tumor may be larger and have spread through several layers of tissue.
The exact details of the T, N and M will depend on the type of cancer.
In addition to TNM staging, you’ll probably hear the doctors use a number staging system. There are usually three or four number stages for each cancer type.
Stage 1 describes a cancer at an early stage when it is usually small in size and hasn’t spread. Stage 4 describes cancer at a more advanced stage, when it has usually spread to other parts of the body. Stages 2 and 3 are in between these stages.
The number stages are made up of different combinations of the TNM stages. So, a stage 1 cancer may be described as either T1, N0, M0, or as T2, N0, M0.
Number stages may also be further subdivided to give more detailed information about tumor size and spread. For example, a stage 3 cancer may be subdivided into stage 3a, 3b and 3c. A stage 3b cancer may differ from a stage 3a cancer either in the tumor size or in whether the cancer has spread to lymph nodes.
Other terms used
You may hear other terms used to describe cancer:
- ‘Early’ or ‘local’ may be used to describe a cancer that hasn’t spread
- ‘Locally advanced’ describes a cancer that has begun to spread into surrounding tissues or nearby lymph nodes
- ‘Local recurrence’ means the cancer has come back in the same area after treatment
- ‘Secondary’, ‘advanced’, ‘widespread’ or ‘metastatic’ means the cancer has spread to other parts of the body.
Grading refers to the appearance of the cancer under the microscope and gives an idea of how quickly the cancer may grow and how likely it is to spread.
- Low-grademeans that the cancer looks like it is slow-growing and is less likely to spread.
- High-grademeans the cancer looks very abnormal, is likely to grow more quickly and is more likely to spread.
Your treatment will usually be carried out in the specialist center that you have been referred to. This may be a hospital with a surgeon who specializes in treating penile cancer, or a cancer treatment center.
The type of treatment you’re given will depend on a number of things, including the position and size of the cancer, whether it has spread and your general health.
The treatments used for penile cancer include surgery, which is the main treatment, radiotherapy and chemotherapy. Advances in surgical techniques mean that it is often possible to preserve the penis or to reconstruct it surgically.
Before you agree to any treatment, your specialist will talk to you about the possible side effects and how to deal with them.
Small, surface cancers that have not spread are treated by removing only the affected area and a small area around it. The cancer can be removed with conventional surgery, by using a laser, or by freezing it with a cold probe (cryotherapy).
If the cancer is affecting only the foreskin, it may be possible to treat it with circumcision alone.
These treatments may be done under local or general anesthetic, depending on individual circumstances. Your doctor can discuss in more detail with you which treatment is appropriate to you and what the after care will involve.
Wide local excision
If the cancer has spread over a wider area, you’ll 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 usually carried out under a general anesthetic and will involve a short stay in hospital.
Removal of lymph nodes
Penis cancer is most likely to spread to the lymph nodes in the groin. If the nodes in your groin are obviously enlarged, or if the nodes that have been tested contain cancer, your surgeon will usually advise you to have all the nodes in your groin removed. This operation is also known as a radical groin dissection, inguinal node dissection or therapeutic groin dissection.
Surgery to preserve the penis and reconstruction
For larger cancers of the head of the penis, the bulbous part (the glans) will be removed. In this situation, it's possible to get back a normal appearance by using skin from somewhere else in the body (called a skin graft).
You will need to stay in hospital for about five days and have the wound dressed regularly for up to a fortnight.
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 tumor. If the tumor is near the base of the penis, total amputation may be the only option. This operation is now much less common, as doctors can usually preserve the penis.
It may be possible to have a penis reconstructed after amputation (if there are no signs that the cancer has spread anywhere else in the body). 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's 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 not done until all your cancer treatment has been completed and after a length of time has passed, so that the surgeon is confident that the risk of the cancer returning is small.
Radiotherapy treats cancer using high-energy rays to destroy cancer cells, while doing as little harm as possible to healthy cells.
Radiotherapy may be used instead of surgery in some situations:
- Where the cancer is small and only affects the head of the penis (glans). However, this is done less often nowadays because of improvements in surgery.
- Where the cancer is large or has spread, and the person is not well enough to have an operation or doesn't want to have surgery.
- Where the cancer has spread to lymph nodes in the groin or deeper into the lower tummy (pelvis). In this case radiotherapy may be used instead of surgery for some people or, more often, after surgery to help reduce the risk of the cancer spreading.
- To treat symptoms such as pain, if the cancer has spread to other parts of the body like the bones.
Radiotherapy is normally given as a series of short daily treatments in the hospital's radiotherapy department. High-energy x-rays are directed at the area of the cancer using a machine that looks very similar to a CT scanner (a scanner used to detect the spread of cancer). The treatments are usually given Monday-Friday with a rest at the weekend. Each treatment takes 10-15 minutes. The number of treatments you’ll have will depend on the type and size of the cancer, and the whole course of treatment for early cancer may take up to six weeks. Your doctor will discuss the treatment and possible side effects with you.
Before each session of radiotherapy, the radiographer (the person that operates the machine) will position you carefully on the couch and make sure that you’re 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 does not make you radioactive, and it’s perfectly safe for you to be around other people, including children, after your treatment.
Side effects of radiotherapy
There are sometimes side effects from radiotherapy treatment to the penis. The skin on your penis or in your groin may become sore during your treatment and for a period of time afterwards. Staff at the radiotherapy department will be able to give advice on how to look after your skin in the area being treated.
Long-term, the side effects of radiotherapy can result in thickening and stiffening of healthy tissues (fibrosis). This can cause a 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 helped by an operation to stretch (dilate) the area. This is done by passing a tube into the urethra and is performed under a general anesthetic. Your doctor can discuss this procedure and its aftercare in more detail with you.
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to kill or shrink the cancer. It can be one drug or several drugs used together. Most chemotherapy is given by injection into a vein (intravenously).
Chemotherapy cream may sometimes be used to treat very small, early cancers that are on the foreskin or end of the penis (glans). Intravenous chemotherapy is mainly used when the cancer has spread to other parts of the body. It may be given before surgery (called neo-adjuvant chemotherapy). It’s quite common to combine it with radiotherapy (called chemoradiotherapy).
Chemotherapy can have a lot of side effects, but these are different for each drug and not everyone is affected in the same way. Your doctor or chemotherapy nurse will discuss the side effects in more detail with you before you have treatment.