Penile cancer is a malignant growth found on the skin or in the tissues of the penis. Squamous cell carcinoma usually originating in the glans or foreskin is by far the most common type, occurring in 9 out of 10 cases. Penile cancer is extremely rare, and it tends to develop in men over the age of sixty.
- 1 Risk factors
- 2 Symptoms
- 3 Pathology
- 4 Staging
- 5 Treatment
- 6 Circumcision as prevention myth
- 7 Incidence of penile cancer
- 8 HPV vaccine
- 9 See also
- 10 External links
- 11 Abbreviations
- 12 References
The major risk factors for penile cancer are advanced age (greater than age 60), use of tobacco, and infection with human papilloma virus.
The myth that smegma was a carcinogenic, and thus that circumcision would render a man immune to penile cancer, was invented in 1932 by a defender of ritual circumcision named Abraham L. Wolbarst, who also believed that circumcision prevented epilepsy, paralysis, and masturbation. No laboratory or clinical research had been done on the subject at the time, however Wolbarst's myth found its way into early medical textbooks regardless. Although the smegma hypothesis was completely disproven by an exhaustive study by Reddy in 1963, circumcision advocates continue to stubbornly repeat it.
Infection with human papilloma virus
The link between the presence of human papillovirus (HPV) and genital cancer was established in the 1980s. Poland identified human papilloma virus (HPV) types 16 and 18 as the cause of penile and cervical cancers in 1990, and that they could be spread by sexual contact. At least one study suggests that circumcised men are at higher risk for HPV infection, making being circumcised a risk factor.
Use of tobacco
Other risks include poor hygiene, and an increased number of sexual partners (30 partners or more).
Phimosis has been implicated as a risk factor in sexually active males, because a non-retractile foreskin may result in poor hygiene, and because men with phimosis are at higher risk for lichen sclerosus (also known as balanitis xerotica obliterans), which may also be a risk factor. Adult males with a non-retractable foreskin who are sexually active may want to have the phimotic condition corrected. (For conservative treatment options, see phimosis.)
Circumcision as a risk factor
Symptoms include redness, irritation, a sore or a lump on the penis.
- A. Precancerous Dermatologic Lesions
- B. Carcinoma in Situ (Bowen Disease, Erythroplasia of Queyrat)
- C. Invasive Carcinoma of the Penis
Like many malignancies, penile cancer can spread to other parts of the body. It is usually a primary malignancy, the initial place from which a cancer spreads in the body. Much less often it is a secondary malignancy, one in which the cancer has spread to the penis from elsewhere. Doctors use the extent of metastasis to estimate what stage the disease is in, to aid in treatment decisions and prognosis. The stages are assessed as follows (Jackson's staging):
- Stage I - Cancer has only affected the glans and/or foreskin.
- Stage II - Cancer has spread to the shaft of the penis.
- Stage III - Mobile (operable) inguinal lymph nodes.
- Stage IV - Fixed (inoperable) inguinal lymph nodes or distant metastasis.
- Recurrent - Cancer that has returned after treatment.
Prognosis can range considerably for patients, depending where on the scale they have been staged. Generally speaking, the earlier the cancer is diagnosed, the better the prognosis. The overall 5-year survival rate for all stages of penile cancer is about 50 percent.
There are several treatment options for penile cancer, depending on staging. They include surgery, radiation therapy, chemotherapy, and biological therapy. The most common treatment is one of five types of surgery:
- Wide local excision - The tumor and some surrounding healthy tissue are removed.
- Microsurgery - Surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible.
- Laser surgery - laser light is used to burn or cut away cancerous cells.
- Circumcision - cancerous foreskin is removed.
- Amputation (penectomy) - a partial or total removal of the penis, and possibly the associated lymph nodes.
Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence. With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy. In addition to all the above, treatment of the underlying disease like Brucellosis, is important to limit disease recurrence.
Circumcision as prevention myth
The myth that circumcision rendered males immune to penile cancer was invented in 1932 by a New York doctor named Abraham L. Wolbarst, M.D.[a 1] Wolbarst wrote an article that was published in The Lancet in 1932, implicating human male smegma as carcinogenic. His hypothesis had absolutely no basis in valid scientific and epidemiological research. Wolbarst was directly responsible for proliferation of this myth, and all subsequent repetitons of it can be traced to his opinion article, although Wolbarst himself advocated universal neonatal circumcision principally as a preventive for epilepsy, paralysis, and masturbation.
Wolbarst's opinion piece led to the perpetuation of the myth that penile cancer could not happen to males that were circumcised in infancy. This myth was completely disproven when Boczko et al. (1979) reported the 9th documented case of penile cancer in a man who had been circumcised in infancy from the time of Wolbarst's opinion piece to the time of the report in 1968 (though they would maintain that "performing [circumcision] in infancy continues to be the most effective prophylactic measure against penile carcinoma"). Boczko et al. (1979) wrote: "The diagnosis in our patient was made late, as in the other cases reported, perhaps because the disease was presumed not to occur in those circumcised in infancy. This is clearly not so. Although rare, the diagnosis must be considered when evaluating a penile lesion even in a circumcised individual."
In 1993, Christopher Maden, Ph.D.[a 2], et al. reported a study in which 110 men with penile cancer, diagnosed from January 1979, to July, 1990, were interviewed. Of these 110 men, 22 had been circumcised at birth, 19 later in life, and 69 never. As cases of penile cancer in circumcised men begin to accumulate, it becomes clear that the assertion that circumcision eliminates the risk of penile cancer is categorically false, although some circumcision advocates continue to make this assertion.
Advocates of circumcision may yet point to the aforementioned studies and highlight that the incidence of penile cancer was still lower in the circumcised groups of men studied, than it was in the intact group, and that thus "a lowered risk of penile cancer is observed in circumcised men." It is important to remember when looking at the studies performed in the 1950s, that the octogenarians afflicted with penile cancer were born in the 1870s, when the circumcision rate in the United States was close to zero; the majority of men in that generation who were afflicted with cancer would be intact. The increased number of cases of penile cancer found in more recent studies is reflective of the steadily increasing circumcision rates in this country (37% of Maden's cases were circumcised). Using Maden's numbers and properly adjusting his control population to match the case population for age, there was no difference in risk of developing penile cancer between men who were circumcised and those who were not. HPV (the cause of genital warts) has been found in most cases of penile cancer. Genital warts are now more common in circumcised men  and HPV lesions are equally common in circumcised and intact men. As the number of circumcised men approaching the age at which penile cancer becomes evident (70s and 80s) it is quite likely that the vast majority of men developing penile cancer in the United States will be circumcised.
Reddy et al. (1975) examined the frequency of carcinoma of the penis from 32 hospitals in India and found a wide variation in incidence that could not be explained by the intact status of the Hindus or the circumcision practices of the Muslims.  Finally, circumcision does not explain why Japan and Denmark have lower penile cancer rates than the United States when circumcision, especially infant circumcision, is not common in those two countries.
In "Circumcision: An American Health Fallacy," Edward Wallerstein writes: "If infant circumcision reduces penile cancer we could expect to see proportionately less penile cancer in circumcising nations as compared to noncircumcising ones. No such difference is found." Wallerstein reports that, for various years between 1966 and 1972, the annual rate of new cases of penile cancer was 0.8 for the United States (where circumcision rates are high), and 0.5 for Finland, 0.9 for Denmark and 1.1 for both Norway and Sweden (all of where circumcision rates are low). None of these differences is statistically significant. Further, within the same time frame, both France and the United States had the same rate, 0.3, of deaths due to penile cancer.
Incidence of penile cancer
In North America the rate of penile cancer has been estimated to be 1 in 100,000. Maden et al. (1993) reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations. Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.
Penile cancer is very rare in Europe and North America, occurring in about one in 100,000 men in the latter. It accounts for 0.2% of cancers and 0.1% of deaths from cancer amongst males in the United States. However, in some parts of Africa and South America it accounts for up to 10% of cancers in men.
In Japan, Norway, and Sweden, the risk of penile cancer is about the same as in the US (1 in 100,000 per year).
The main article for this is [HPV vaccine] on Wikipedia.
Infection with HPV is associated with some penile cancers. A quadri-valent vaccine (Gardasil) to prevent infection by the four most common variants of HPV has been developed, successfully tested, and approved by the US Food and Drug Administration for females between the ages of 9 and 26, and as of 2009, males between the ages of 16 and 26. Gardasil has been shown to also be effective in males, and has been approved by the FDA to be marketed as such. Two to three doses are necessary.
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