Demographic and socioeconomic predictors of treatment delays, pathologic stage, and survival among patients with penile cancer: A report from the National Cancer Database

Impact of pathologic features on local recurrence in penile squamous cell carcinoma after penectomy

BACKGROUND

Penile squamous cell carcinoma (PSCC) is a rare malignancy that may be cured in cases of local disease by resection of the primary tumor. Risk factors and patterns of local recurrence (LR) have not been well described in cases requiring partial or radical penectomy. In this study, we evaluated risk factors for LR and the impact of frozen and final margin assessment.

MATERIALS AND METHODS

We evaluated 119 patients with PSCC who had undergone partial or radical penectomy from 2007 to 2023. Data regarding clinical and pathologic features were collected by retrospective chart review. The primary outcome of interest was LR. Determinants of LR were analyzed by Student's t, Fisher's exact, chi-square and logistic regression analysis. Predictive statistics of frozen margin status on final margin were assessed and LR rates for subsets of frozen and final margin interaction were defined. Finally, all cases of positive margins and LR were described to highlight patterns of LR and the importance of margin status in these cases.

RESULTS

There were 8 (6.7%) cases of local recurrence. There were no significant predictors of LR, although a trend toward increased LR risk was observed among those with a positive final margin. Positive final margins were found in 15 (13%) cases. Frozen margin analysis was utilized in 79 cases, of which 10 (13%) were positive. The sensitivity, specificity, positive predictive value, and negative predictive value of frozen margin status for final margins were 44%, 92%, 40%, and 93%, respectively. There were no LR among cases in which frozen margin was not sent. Analysis of all cases with positive margin and/or LR identified three subsets of patients: CIS or focally positive margin resulting in either no LR or LR managed with minimal local intervention, bulky disease in which survival is determined by response to subsequent therapy rather than local recurrence, and clinically significant local recurrence requiring continued surveillance and intervention despite negative margins.

CONCLUSIONS

LR is rare, even in cases of larger, proximal tumors requiring partial or radical penectomy. In this study, no statistically significant risk factors for local recurrence were identified; however, analysis of frozen and final margins provided insight into the importance of margin status and patterns of local recurrence. When feasible, visibly intra-operative negative margins are an excellent predictor of low risk for LR, and, in cases of CIS or focally positive margins, further resection to achieve negative margins is unlikely to reduce the risk of clinically significant LR. Additionally, in cases of bulky disease, the goals of resection should be focused toward palliation and next line therapy.

Influence of Race/Ethnicity and Household Median Income on Penile Cancer Mortality

INTRODUCTION

Penile cancer, while relatively rare in developed nations, presents substantial disparities in outcomes among different demographic groups. Previous research has shown race/ethnicity and socioeconomic status, often proxied by household median income, to be critical determinants of health outcomes across various diseases.

OBJECTIVE

This study examines the association of race/ethnicity and household median income with survival among penile cancer patients in the United States.

METHODS

We utilized the Surveillance, Epidemiology, and End Results (SEER) Registry to identify patients with a primary diagnosis of penile malignancies from 2000 to 2019. Our primary outcome of interest was the hazard of death following a diagnosis of penile cancer. We utilized the Cox regression model to explore the association between race/ethnicity and median household income and how this influences survival among these patients. We adjusted for patients' characteristics, disease stage at presentation, and treatment modalities.

RESULT

Of the 6,520 penile cancer patients identified, 5,242 (80.4%) had primary malignancies. The distribution of patients was as follows: 64.1% non-Hispanic Whites, 8.9% non-Hispanic Blacks, 20.8% Hispanics, and 6.2% from other racial/ethnic groups. The median diagnosis age was 66 years (interquartile range: 56-74). Survival rates at 5, 10, and 15 years showed racial disparities: 76.4%, 72.5%, and 69.7% for non-Hispanic Whites; 70.6%, 64.1%, and 61.1% for non-Hispanic Blacks; and 70.5%, 67.4%, and 65.6% for Hispanics. Multivariate Cox regression revealed worst survival for Black (HR=1.40; 95% CI=1.08-1.81, p=0.01) and Hispanic patients (HR=1.24; 95% CI=1.01-1.52, p=0.04). No association was found between median household income and survival. Interaction analysis indicated that the poorest Black men had worse outcomes than the poorest Whites did (HR=2.08; 95% CI=1.27-3.41, p=0.003).

CONCLUSION

Survival rates for non-Hispanic Black and Hispanic patients are significantly lower than those for non-Hispanic Whites. Furthermore, survival is worse for low-income Black patients than their White counterparts in the same income bracket.

The Burden of HPV-Related Hospitalizations: Analysis of Hospital Discharge Records from the Years 2015-2021 from a Southern Italian Region

(1) Background: The human papillomavirus (HPV) is the most common agent related to sexually transmitted infections in the general population. Its genotypes are classified into two main classes, high-risk genotypes and low-risk genotypes, according to their capacity to induce cancers. The low-risk class (types 6 and 11) is associated with anogenital and genital lesions. The high-risk class is responsible for up to 4.5% of all new cancer cases yearly. The aim of this study was to evaluate the incidence of HPV-related hospitalizations and its trend in a southern Italian region for the years 2015-2021. (2) Methods: This was a retrospective study performed in the Abruzzo region, Italy. All admissions for the period 2015-2021 were extracted from the hospital discharge record (HDR). (3) Results: During the study period (2015-2021), a total of 5492 hospitalizations attributable to HPV infection occurred in the Abruzzo region, Italy. A significant number of admissions were related to cervical cancer (3386 cases) and genital warts (638 cases). The trend declined for all diagnoses except for penile cancer admissions. Considering the first year of the pandemic (year 2020), a decrease in the standardized incidence of the majority of the diseases considered was reported, particularly among cases of cervical cancer. (4) Conclusions: HPV-related hospitalizations decreased in Abruzzo during study period. These results could be useful to LHAs and policy-makers in improving vaccination coverage and screening adherence.

Clinical Profile and Predictors of Survival in Carcinoma Penis Patients

BACKGROUND

Carcinoma penis is a rare neoplasm, and the literature is scarce on long-term survival and its predictors. The aim of the study was to determine the clinical profile and management patterns, identify predictors of survival, and the impact of education and rural/urban dwelling on survival.

METHODS

Patients with a histological diagnosis of carcinoma penis from January 2015 to December 2019 were included in the study. Demographics, clinical profile, education status, primary residence address, and outcomes were obtained from the case records. Distance from the treatment centre was obtained from the postal code. The primary objectives were to assess relapse-free survival (RFS) and overall survival (OS). The secondary objectives were to identify the predictors of RFS and OS and to determine the clinical profile and treatment patterns in patients with carcinoma penis in India. Time-to-event was calculated by Kaplan-Meir analysis and survival was compared by the log-rank test. Univariate and multivariable Cox regression analyses were used to find independent predictors of relapse and mortality. Logistic regression analyses to examine the associations of rural residence, education status, and distance from the treatment centre with the relapse adjusting for measured confounding variables.

RESULTS

Case records of 102 patients treated during the above period were retrieved. The median age was 55.5 (interquartile range [IQR] 42-65 years). Ulcero-proliferative growth (65%), pain (57%), and dysuria (36%) were the most common presenting features. Clinical examination or imaging revealed inguinal lymphadenopathy in 70.6% of patients, however, only 42% of these lesions were pathologically involved. A total of 58.8% of patients were from rural areas, 46.9% had no formal education, and 50.9% had a primary residence ≥100 km from the hospital. Patients with lower education and rural households had higher TNM stages and nodal involvement. Median RFS and OS were 57.6 months (15.8 months to not reached) and 83.9 months (32.5 months to not reached), respectively. On univariate analysis tumor stage, involvement of lymph nodes, T stage, performance status, and albumin was predictive for relapse and survival. However, on multivariate analysis, the stage remained the only predictor of RFS and nodal involvement, and metastatic disease was a predictor of OS. Education status, rural habitation, and distance from the treatment centre were not predictors for relapse or survival.

CONCLUSIONS

Patients with carcinoma have locally advanced disease at presentation. Rural dwellings and lower education were associated with the advanced stage but did not have a significant bearing on the survival outcomes. The stage at diagnosis and nodal involvement is the most important predictor of RFS and OS.

Increased HRD score in cisplatin resistant penile cancer cells

BACKGROUND/INTRODUCTION

Penile cancer is a rare disease in demand for new therapeutic options. Frequently used combination chemotherapy with 5 fluorouracil (5-FU) and cisplatin (CDDP) in patients with metastatic penile cancer mostly results in the development of acquired drug resistance. Availability of cell culture models with acquired resistance against standard therapy could help to understand molecular mechanisms underlying chemotherapy resistance and to identify candidate treatments for an efficient second line therapy.

METHODS

We generated a cell line from a humanpapilloma virus (HPV) negative penile squamous cell carcinoma (UKF-PEC-1). This cell line was subject to chronic exposure to chemotherapy with CDDP and / or 5-FU to induce acquired resistance in the newly established chemo-resistant sublines (PEC-1^rCDDP²⁵⁰⁰, adapted to 2500 ng/ml CDDP; UKF-PEC-1^r5-FU⁵⁰⁰, adapted to 500 ng/ml 5- FU; UKF-PEC1^rCDDP²⁵⁰⁰/^r5-FU⁵⁰⁰, adapted to 2500 ng/ml CDDP and 500 ng/ml 5 -FU). Afterwards cell line pellets were formalin-fixed, paraffin embedded and subject to sequencing as well as testing for homologous recombination deficiency (HRD). Additionally, exemplary immunohistochemical stainings for p53 and gammaH2AX were applied for verification purposes. Finally, UKF-PEC-1^rCDDP²⁵⁰⁰, UKF-PEC-1^r5-FU⁵⁰⁰, UKF-PEC1^rCDDP²⁵⁰⁰/^r5-FU⁵⁰⁰, and UKF-PEC-3 (an alternative penis cancer cell line) were tested for sensitivity to paclitaxel, docetaxel, olaparib, and rucaparib.

RESULTS AND CONCLUSIONS

The chemo-resistant sublines differed in their mutational landscapes. UKF-PEC-1^rCDDP²⁵⁰⁰ was characterized by an increased HRD score, which is supposed to be associated with increased PARP inhibitor and immune checkpoint inhibitor sensitivity in cancer. However, UKF-PEC-1^rCDDP²⁵⁰⁰ did not display sensitivity to PARP inhibitors.

Análise do Tempo para Início do Tratamento Oncológico no Brasil: Fatores Demográficos e Relacionados à Neoplasia

Introdução: E reservado a todo brasileiro com câncer, pela Lei dos 60 Dias, o direito de começar o tratamento em até dois meses. Todavia, estudos anteriores apontam a dificuldade dos pacientes em fazer valer essa normativa ao esbarrarem em problemáticas macroestruturais dos sistemas de saúde. Objetivo: Avaliar a influência de fatores demográficos e relacionados a neoplasia sobre o tempo para início do tratamento oncológico no Brasil. Método: Estudo seccional, desenvolvido com dados oriundos do PAINEL-Oncologia, uma base publica nacional, alimentada por diversas fontes de informação do Sistema Único de Saúde. Como variáveis de interesse, elegeram-se: a) tempo de tratamento; b) sexo; c) idade; d) diagnostico; e) estadiamento; f) modalidade terapêutica. Então, foi analisado o tempo transcorrido entre o diagnóstico e o início do tratamento oncológico. Resultados: Percebeu-se aumento exponencial, ao longo dos anos, da proporção de casos tratados oportunamente, isto e, em até 60 dias, como regulamenta a Lei. Entretanto, ainda e considerável a prevalência de atrasos no início do tratamento, sobretudo entre indivíduos idosos, do sexo masculino, com canceres em estádios menos avançados e que precisaram de radioterapia como primeira modalidade terapêutica. Além disso, o tempo de espera foi especialmente maior para os canceres de órgãos genitais masculinos, de cabeça e pescoço e de mama. Conclusão: Alguns fatores demográficos e relacionados a neoplasia estão envolvidos no atraso do início da terapia oncológica.

Patterns of Treatment and Outcomes in Older Men With Penile Cancer: A SEER Dataset Analysis

Purpose

To evaluate clinicopathologic and treatment characteristics from a population-based cohort of penile cancer, with an emphasis in older adults, due to incomplete evidence to guide therapy in this age subgroup.

Materials and Methods

Patients with malignant penile tumors diagnosed 2004-2016 were identified in the Surveillance, Epidemiology and End Results Program (SEER)-18 dataset. Demographic and treatment characteristics were obtained. Population was analyzed by age at diagnosis (<65 vs ≥65 years). We examined univariate associations between age groups with Chi-square analysis. To study survival, we calculated Kaplan-Meier survival curves, but due to the high number of competing events, we also performed a univariate competing risk analysis using the cumulative incidence function, and a multivariate analysis using the Fine-Gray method. We also described competing mortality due to penile cancer and other causes of death.

Results

We included 3,784 patients. Median age was 68 years, 58.7% were aged ≥65. Older patients were less likely to have received chemotherapy (p<0.001), primary site surgery (p = 0.002), or therapeutic regional surgery (p <0.001). Median overall survival (OS) in patients <65 years was not reached (95% CI incalculable) vs 49 months in those ≥65 years (95% CI 45-53, p <0.0001). On univariate analysis, age was associated with a lower incidence of penile cancer death. On multivariate analysis, stage at diagnosis, and receipt of primary site surgery were associated with a higher incidence of penile cancer death. Estimated penile cancer-specific mortality was higher in patients <65 years in stages II-IV. Estimated mortality due to other causes was higher in older patients across all stages.

Conclusions

Older patients are less likely to receive surgery, chemotherapy and radiotherapy for penile cancer. Primary surgical resection was associated with better penile cancer-specific mortality on multivariate analysis. Competing mortality risks are highly relevant when considering OS in older adults with penile cancer. Factors associated with undertreatment of older patients with penile cancer need to be studied, in order to develop treatment strategies tailored for this population.

Trends in Incidence, Mortality, and Survival of Penile Cancer in the United States: A Population-Based Study

Purpose

The aim of this study is to investigate the trends in incidence and mortality, and explore any change in survival of penile cancer in the United States.

Methods

We obtained data from the Surveillance, Epidemiology, and End Results (SEER) database (2000–2018) utilizing the SEER Stat software. The joinpoint regression was used to analyze the secular trend of incidence and incidence-based mortality (IBM) stratified by age, race, and summary stage. The 5-year relative survival rate was also calculated.

Result

The age-adjusted rates of penile cancer patients were 0.38 (0.37–0.39) and 0.21 (0.2–0.21) for overall incidence and IBM, respectively. The 5-year relative survival rates were 67.7%, 66.99%, and 65.67% for the calendar periods of 2000–2004, 2005–2009, and 2010–2014, respectively. No significant changes in incidence by era were observed from 2000 to 2018 [annual percentage change (APC) = 0.5%, p = 0.064]. The IBM rate of penile cancer showed an initial significant increase from 2000 to 2002 (APC = 78.6%, 95% CI, −1.7–224.6) followed by a deceleration rate of 4.6% (95% CI, 3.9–5.3) during 2002 to 2018. No significant improvement in 5-year relative survival was observed. The trends by age, race, and summary stage in incidence and IBM were significantly different.

Conclusion

This study, using population-level data from the SEER database, showed an increasing trend in IBM and no significant improvement in the 5-year relative survival rate. Meanwhile, the incidence of penile cancer exhibited a relatively stable trend during the study period. These results might be due to the lack of significant progress in the treatment and management of penile cancer patients in the United States in recent decades. More efforts, like increasing awareness among the general population and doctors, and centralized management, might be needed in the future to improve the survival of this rare disease.

A global approach to improving penile cancer care

Rare tumours such as penile carcinoma have been largely neglected by the urology scientific community in favour of more common - and, therefore, more easily fundable - diseases. Nevertheless, penile cancer represents a rising burden for health-care systems around the world, because a lack of widespread expertise, ineffective centralization of care and absence of research funds have hampered our ability to improve the global care of these patients. Moreover, a dichotomy has arisen in the field of penile cancer, further impeding care: the countries that are mainly supporting research on this topic through the development of epidemiological studies and design of clinical trials are not the countries that have the highest prevalence of the disease. This situation means that randomized controlled trials in developed countries often do not meet the minimum accrual and are intended to close before reaching their end points, whereas trials are almost completely absent in those areas with the highest disease prevalence and probability of successful recruitment, such as Africa, South America and South Asia. The scientific and organizational inaction that arises owing to this mismatch translates into a burdensome cost for our patients. A global effort to gather experts and pull together scientific data from around the world may be the best way to boost clinical research, to change clinical practice and, ultimately, to improve care for patients and their families.

Representation in Figures Depicting Penile Pathology in Urologic Textbooks

OBJECTIVE

To investigate whether penile pathologies are presented diversely in urologic textbooks and identify areas where more diverse presentation is warranted.

METHODS

Photographic depictions of penile pathologies in 9 urologic textbooks were assigned a Fitzpatrick skin phototype and constitutive skin color. Fitzpatrick skin phototypes ranged from I to VI, and constitutive skin colors were light, fair, medium, and dark. Fitzpatrick skin phototypes I-III were deemed nonskin of color, and IV-VI considered skin of color. Figures were classified based on pathology presented: infectious benign or sexually transmitted infection (STI), noninfectious benign, or malignant. Chi-square and odds ratios were used to compare skin color ranges across pathologic categories and determine where a figure depicting skin color would most likely be encountered.

RESULTS

Within 116 figures meeting inclusion criteria, 15 (51.7%) infectious/STI pathologies displayed skin of color, while 10 (27.8%) noninfectious benign and 7 (13.7%) malignant pathologies displayed skin of color. Within 85 diagnostic images, 15 (51.7%) images of infections/STIs, 10 (28.6%) noninfectious benign, and 4 (19.0%) malignant pathologies presented skin of color (P < 0.01). Overall, images of patients with skin of color were more likely depictions of infections/STIs than any other pathology (P < .001, OR = 2.26).

CONCLUSION

There is a lack of depictions of malignant and noninfectious benign penile pathology on the skin of color. This may contribute to continued disparities in the diagnosis and treatment of penile pathologies.

Underutilization of Surgical Standard of Care for Insured Men with Invasive Penile Cancer

PURPOSE

Prior studies of mixed insurance populations have demonstrated poor adherence to surgical standard of care (SOC) for penile cancer. We used data from the Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare to calculate SOC adherence to surgical treatment of penile cancer in insured men over the age of 65, focusing on potential social and racial disparities.

METHODS

This is an observational analysis of patients with T2-4 penile cancer of any histologic subtype without metastasis in the SEER-Medicare database (2004-2015). SOC was defined as penectomy (partial or radical) with bilateral inguinal lymph node dissection (ILND) based on the National Comprehensive Cancer Network guidelines. We calculated proportions of those receiving SOC and constructed multivariate models to identify factors associated with receiving SOC.

RESULTS

A total of 447 men were included. Of these men, 22.1% (99/447) received SOC while 18.8% (84/447) received no treatment at all. Only 23.3% (104/447) had ILND while 80.9% (362/447) underwent total or partial penectomy. Race and socioeconomic status (SES) were not associated with decreased SOC. Increasing age (OR 0.93, 95%CI:0.89-0.96), Charlson Comorbidity Index score ≥ 2 (OR 0.53, 95%CI:0.29-0.97), and T3-T4 disease (OR 0.34, 95%CI:0.18-0.65) were associated with not receiving SOC on adjusted analysis.

CONCLUSIONS

Rates of SOC are low among insured men 65 years of age or older with invasive penile cancer, regardless of race or SES. This finding is largely driven by low rates of ILND. Strategies are needed to overcome barriers to SOC treatment for men with invasive penile cancer.

A Clinical Nomogram for Predicting Lymph Node Metastasis in Penile Cancer: A SEER-Based Study

Purpose: We developed a nomogram to predict the possibility of lymph node metastasis in patients with squamous cell carcinoma of the penis.

Methods: Identifying patients with squamous cell carcinoma of the penis diagnosed between 2004 and 2015 in the Surveillance, Epidemiology, and End Results (SEER) database. Univariate and multivariate analyses were carried out by logistic regression to assess significant predictors associated with lymph node metastasis. A nomogram was established and validated by a calibration plot and receptor operating characteristic curve (ROC) analysis.

Results: A total of 1,016 patients with penile squamous cell carcinoma (SCCP) were enrolled in this study. One hundred and ninety-five patients (19%) had lymph node involvement (N1-3). Multivariate analysis showed that age, primary tumor site, grade, tumor size, and T stage were identified as being significantly (p < 0.05) associated with lymph node involvement. All the above factors that showed a statistically significant predictive capability were selected for building the nomogram. This model had a calibration slope of 0.9 and a c-index of 0.776, indicating the good discrimination and effectiveness of the nomogram in predicting lymph node status.

Conclusion: Although the prediction model has some limitations, the nomogram revealed the relationship between the clinicopathological characteristics of SCCP patients and the risk of lymph node metastasis. This tool will assist patients in counseling and guide treatment decisions for SCCP patients.

DaPeCa-9 - cohabitation and socio-economic conditions predict penile cancer-specific survival in a national clinical study from Denmark

BACKGROUND

Cohabitation and social conditions predict prognosis in several cancers; recent data suggest this might also be the case in penile cancer.

OBJECTIVE

To assess the prognostic significance of cohabitation, living arrangements and socio-economic conditions for cancer-specific survival (CSS) in patients with penile squamous cell carcinoma (pSCC).

METHODS

We retrospectively evaluated CSS in 429 pSCC patients from a 10-year period. We assessed cohabitation, living arrangements and socio-economic conditions(SEC) as prognostic predictors. Kaplan-Meier estimates and Cox hazard rates (HR) with 95% confidence intervals were used for analysis.

RESULTS

Out of 429 pSCC patients, 137 (32%) were living alone and 292 (68%) were cohabiting. With a Cox HR at 1.91 (95% CI 1.3-2.98) patients living alone had a significantly lower median five-year survival rate at 69% (95% CI 60-77%) compared to cohabiting patients at 83% (95% CI 78-87%), p = 0.002. Comparing 60 (14%) from higher to 202 (47%) from medium and 95 (22%) patients from lower socio-economic groups we found Cox HRs at 1, 2.4 (95% CI 1.0-5.7, p = 0.04) and 3.4 (95% CI 1.4-8.1, p < 0.01) respectively. When comparing living arrangements, the trend that patients living in apartments and institutions had poorer outcomes than patients living in a house did not reach statistical significance.

CONCLUSIONS

Living alone and in poor socio-economic conditions predict poor prognosis in penile cancer in this national study. We make the case for further research in efforts to minimize cancer inequality pSCC patients.

Novel Prognostic Models for Patients With Penile Carcinoma

Although penile carcinoma is a rare malignancy, there is still an unmet need to identify prognostic factors associated with poor survival. In this study, we utilized demographic and clinical information to identify the most informative variables associated with overall survival in patients with penile cancer. From a full model including all covariates found to be statistically significant in univariable analyses, we identified a parsimonious reduced model containing tumor site (penis glans: hazard ratio [HR] = 0.48; 95% CI: 0.28-0.85 and penis not otherwise specified: HR = 0.45; 95% CI: 0.25-0.84), undetermined tumor differentiation (HR = 0.48; 95% CI: 0.27-0.86), and TNM stage III/IV (HR = 2.83; 95% CI: 1.68-4.75). When all of the covariates from the full model were subjected to classification and regression tree analysis, we identified 6 novel risk groups. Of particular interest, we found marriage was associated with substantial improvement in survival among men with the same stage and disease site. Specifically, among single/widowed/divorced men with TNM stage 0-II and prepuce/penis corpus/overlapping lesions had worse survival (5-year survival = 18.2%) versus married men (5-year survival = 62.5%). Since marital status is linked to social support, these findings warrant a deeper investigation into the relationships between disease prognosis and social support in patients with penile carcinoma.

Penile Sparing Techniques For Penile Cancer

Penile cancers are rare malignancies. Traditional surgical options, including partial and total penectomy, can dramatically affect a patient's quality of life and mental health. In select patients, penile sparing techniques (PST) have the potential to remove the primary tumor with comparable oncologic outcomes while maintaining penile length, sexual function, and urinary function. In this review, we aim to discuss the indications, advantages, and outcomes of the various PST currently available for men seeking an organ-preserving option for their penile cancer.

Education level as a predictor of survival in patients with multiple myeloma

BACKGROUND

Disparities in multiple myeloma (MM) prognosis based on sociodemographic factors may exist. We investigated whether education level at diagnosis influenced Chinese MM patient outcomes.

METHODS

We performed a multicenter retrospective analysis of data from 773 MM patients across 9 centers in China from 2006 to 2019. Sociodemographic and clinical factors at diagnosis and treatment regimens were recorded, and univariate and multivariate analyses were performed.

RESULTS

Overall, 69.2% of patients had low education levels. Patients with low education levels differed from those with high education levels in that they were more likely to be older, and a higher proportion lived in rural areas, were unemployed, had lower annual incomes and lacked insurance. Additionally, compared to patients with high education levels, patients with low education levels had a higher proportion of international staging system (ISS) stage III classification and elevated lactate dehydrogenase (LDH) levels and underwent transplantation less often. Patients with high education levels had a median progression-free survival (PFS) of 67.50 (95% confidence interval (CI): 51.66-83.39) months, which was better than that of patients with low education levels (30.60 months, 95% CI: 27.38-33.82, p < 0.001). Similarly, patients with high education levels had a median overall survival (OS) of 122.27 (95% CI: 117.05-127.49) months, which was also better than that of patients with low education levels (58.83 months, 95% CI: 48.87-62.79, p < 0.001). In the multivariable analysis, patients with high education levels had lower relapse rates and higher survival rates than did those with low education level in terms of PFS and OS (hazard ratio (HR) = 0.50 [95% CI: 0.34-0.72], p < 0.001; HR = 0.32 [0.19-0.56], p < 0.001, respectively).

CONCLUSIONS

Low education levels may independently predict poor survival in MM patients in China.

A National Cancer Database-based nomogram to predict lymph node metastasis in penile cancer

OBJECTIVE

To evaluate the predictive nature of several clinicopathological variables by developing a nomogram predictive for lymph node-positive disease using the National Cancer Database cohort of patients with squamous cell carcinoma of the penis.

METHODS

Stepwise logistic regression was used to find the best-fit model; remaining clinical variables were used to create a nomogram to predict the probability of lymph node-positive disease.

RESULTS

On multivariate analysis, high pathological grade (3-4 vs 1: odds ratio [OR] 3.27, 95% confidence interval [CI] 1.70-6.29; 2 vs 1: OR 2.58, 95% CI 1.39-4.79 [P = 0.002]), lymphovascular invasion (OR 2.49, 95% CI 1.61-3.84 [P < 0.001]), and positive clinical lymph node status (N1 vs N0: OR 20.0, 95% CI 11.4-35.7; N2 vs N0: OR 27.8, 95% CI 14.1-55.6; N3 vs N0: OR 49.2, 95% CI 14.8-162.8 [P < 0.001]) were predictors of lymph node metastasis in penile cancer. The bootstrap-corrected concordance index of this nomogram was 0.880.

CONCLUSION

Using tumour grade, tumour lymphovascular invasion and clinical lymph node status, we developed a nomogram highly predictive of pathologial lymph node metastasis that, after further external validation, could be helpful in the surgical decision-making process.

The Diagnosis and Treatment of Penile Cancer

BACKGROUND

The incidence of penile cancer in Europe lies in the range of 0.9 to 2.1 cases per 100 000 persons per year. Carcinogenesis is associated with human papilloma virus (HPV) infection and with chronic inflammation.

METHODS

This review is based on publications (2010-2017) retrieved by a selective search in PubMed and EMBASE and on the guidelines of the European Association of Urology, the European Society of Medical Oncology, the National Comprehensive Cancer Network, and the National Institute for Health and Care Excellence (NICE).

RESULTS

95% of cases of penile cancer are accounted for by squamous cell carcinoma, whose numerous subtypes have different clinical courses. Chronic preputial inflammation due to phimosis or lichen sclerosus is often associated with penile cancer. Circumcision lowers the risk of penile cancer (hazard ratio: 0.33). Maximally organ-preserving surgery with safety margins of no more than a few millimeters is the current therapeutic standard, because a local recurrence, if it arises, can still be treated locally with curative intent. Local radiotherapy can be performed in early stages. Lymphogenic metastasis must be treated with radical lymphadenectomy and adjuvant chemotherapy. Patients with clinically unremarkable inguinal lymph nodes nonetheless need invasive lymph node staging because of the high rate of lymphogenic micrometastasis.

CONCLUSION

Penile cancer is curable in all early stages with the appropriate treatment, but its prognosis depends crucially on the proper management of the regional (i.e., inguinal) lymph nodes. In many countries, the treatment of this rare disease entity has been centralized.