Global Burden of Penile Cancer: A Review of Health Disparities for a Rare Disease

We performed a narrative review evaluating the influence of race and socioeconomic status for penile cancer patients based on region. We found higher incidence in underdeveloped nations. Globally, HPV-associated tumors are more prevalent, particularly in areas with high HPV and HIV infection. Socioeconomic determinants exacerbated these disparities. Similarly, in the United States, disparities were notable among racial and ethnic groups, with black men having worse survival. Understanding sociodemographic differences may help mitigate disparities by improving access to care with targeted interventions including education on risk factors and HPV vaccination to reduce penile cancer burden in vulnerable parts of the world.

Exploring the Multifactorial Landscape of Penile Cancer: A Comprehensive Analysis of Risk Factors

Penile cancer, while rare, is a critical public health issue due to its profound impact on patients and the complexities of its management. The disease's multifactorial etiology includes risk factors such as HPV infection, poor hygiene, smoking, genetic predispositions, and socioeconomic determinants. This article provides a comprehensive review and analysis of these diverse risk factors, aiming to enhance understanding of the disease's underlying causes. By elucidating these factors, the article seeks to inform and improve prevention strategies, early detection methods, and therapeutic interventions. A nuanced grasp of the multifactorial nature of penile cancer can enable healthcare professionals to develop more effective approaches to reducing incidence rates and improving patient outcomes.

Trends in HPV-associated cancer incidence in Texas medically underserved regions

BACKGROUND

While cervical cancer incidence rates (IR) in the United States have dropped in the last 20 years, non-cervical human papillomavirus (HPV) associated cancers increased. Many people in Texas (TX) live in medically underserved areas and have higher risk of developing HPV-associated cancers. Since previous studies of these regions focused on cervical cancer, we included other HPV-associated cancers in our analysis of IR in East TX and the TX-Mexico Border compared to other TX regions.

METHODS

Cancer data from 2006 to 2019 were obtained from the TX Cancer Registry. Cases of HPV-associated cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers and corresponding patient-level demographic data were included. We calculated IR per 100,000 and drew heat maps to visualize cancer IR by county. To control potential confounders, we added county-level risk factors: rates for smoking, excessive drinking, obesity, STIs, primary care provider availability and dentist availability, from the County Health Rankings and Roadmaps program. We reported IRs by region and time and estimated unadjusted and adjusted risk ratio (RR) for association of each type of cancer and region. Lastly, we created adjusted models for each cancer by period to see time trends of regional differences.

RESULTS

Risk of anal, cervical, and oropharyngeal cancer was lower at parts of the Border than in the rest of TX in the adjusted model. We also observed increasing anal and oropharyngeal cancer risk and decreasing cervical and vaginal cancer risk over time.

CONCLUSION

Patient sociodemographics, behavioral risk factors, and access to care may contribute to some observed differences in cancer IR across regions. This indicates that targeted prevention efforts towards these regions, especially in low socioeconomic status communities, may benefit future generations.

Increasing diversity in clinical trials: demographic trends at the National Cancer Institute, 2005-2020

BACKGROUND

We described participant demographics for National Cancer Institute (NCI) clinical trials at the clinical center (NCI-CC participants) of the National Institutes of Health to identify enrollment disparities.

METHODS

We analyzed NCI-CC data from 2005 to 2020, calculated enrollment fractions, compared with the US cancer population represented by the Surveillance, Epidemiology, and End Results cancer incidence data (2018) and the Cancer in North America database (2018), and compared further with clinical trial disparities data from the NCI Community Oncology Research Program and National Clinical Trials Network (2005-2019), and from ClinicalTrials.gov (2003-2016).

RESULTS

NCI-CC (38 531 participants) had higher enrollment fractions for older adults (8.5%), male (5.6%), non-Hispanic (5.1%), and Black or African American (5.3%) participants; lower women proportion across race and ethnicity; and fewer female sex-specific cancer (6.8%) than male sex-specific cancer (11.7%) participants. NCI-CC had lower median age than Surveillance, Epidemiology, and End Results (54.0 vs 65.4); more Black or African American participants (12.0% vs 11.1%); and fewer women (41.7% vs 49.5%), White (76.1% vs 80.5%), Asian or Pacific Islander (4.6% vs 6.0%), American Indian or Alaska Native (0.3% vs 0.5%), and Hispanic participants (7.1% vs 13%). NCI-CC had more Black or African American and Asian or Pacific Islander participants; fewer Hispanic participants than the NCI Community Oncology Research Program and National Clinical Trials Network; more Black or African American and Hispanic participants; fewer Asian or Pacific Islander participants than ClinicalTrials.gov data. Improvement was noted for NCI-CC (older adults, Black or African American, Asian or Pacific Islander, Hispanic participants).

CONCLUSION

We found lower representation of older adults, women, Asian or Pacific Islander, American Indian or Alaska Native, and Hispanic participants vs the US cancer population and higher representation of Black or African American vs US cancer population and oncology clinical trials. Multifaceted efforts are underway to reduce disparities in cancer clinical trials at the NCI-CC.

Penile Cancer Mortality in Brazil: Are We Making Progress?

PURPOSE

This study aims to analyze the trends in mortality rates from penile cancer (PeC) and the treatment modalities adopted in Brazil over recent years.

MATERIALS AND METHODS

Death records for PeC cases (International Classification of Diseases, version 10 C60) and treatment modalities were extracted from the DATASUS database. A joinpoint regression analysis was conducted to examine the data.

RESULTS

A total of 7,848 deaths due to PeC were recorded in Brazil between 1996 and 2020. Increasing mortality trends were observed, with an average annual percentage change (AAPC) of 0.91 (0.6-1.2; P < .001). The North and Northeast regions had the highest age-standardized mortality rates (ASMRs) and AAPCs. From 2008 to 2020, the ASMR in the Northeast region remained stable, whereas the North region surpassed it. The Southeast region exhibited a significant downward trend, with an AAPC of -0.91 (-1.3 to -0.5; P < .001). Penile biopsies declined and were more frequent in the southeastern region. A total of 8,498 penile amputations were performed, with 39.4% and 29.1% conducted in the Southeast and Northeast regions, respectively.

CONCLUSION

Brazil has experienced increasing mortality trends in PeC over the past 2 decades. Low schooling, married, and young men from the North or Northeast regions represent the majority of deaths. Urgent efforts are needed to enhance the diagnosis and treatment of PeC to prevent and reduce mortality rates in the country.

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.

Disparities in Healthcare Access, Education, and Geographical Factors That Affect Surgical Outcomes in Penile Cancer

Objectives: To establish the level of access to healthcare, education, social and geographical factors predisposing a negative surgical outcome and higher mortality rate in patients with penile cancer.

Methods: This is a retrospective, longitudinal and analytical study. Ninety-three medical records of adult male patients diagnosed with penile cancer were reviewed. Fisher’s exact test was performed to determine the association between the level of healthcare, social and geographical factors, and the outcomes for penile cancer.

Results: Patients without primary care access had a higher chance of having lymphovascular invasion at the time of diagnosis (OR=37.5, P<0.0001), a higher mortality rate at 24 months after diagnosis (OR=19.2, P=0.005), a lack of high school diploma or equivalent (OR=3.8, P=0.049) and a higher likelihood of referral from a provincial hospital (OR=10.1, P<0.0001). Patients without a favorable surgical outcome (radical penectomy) were more likely to have been referred from a provincial hospital (OR=6.8, P<0.0001) and not have access to a primary care center (OR=149.5, P<0.0001), a tertiary care center (OR=20.7, P=0.003), and a high school diploma (OR=7.9, P=0.004). 

Conclusions: The lack of access to primary care is strongly associated with vascular invasion at diagnosis, lower educational level, a referral from provincial zones, and a higher mortality rate at 24 months. Patients who did not have access to primary and tertiary care, a high school diploma, and were referred from the province were more likely to have a radical penectomy.

Is tailored messaging more effective? An analysis of a digital health intervention to promote HPV vaccination intent among Latinx

Latinx populations have unique barriers to HPV vaccination. In the current study, we assessed the effectiveness of an online intervention to increase HPV vaccination intentions among patients of clinics that principally serve a Latinx population (n = 85%) as part of a randomized control trial (RCT). Participants viewed on an iPad either an individually tailored educational website (CHiCOS) or untailored information derived from the Vaccine Information Sheet (VIS) for HPV. Vaccination intention and related covariates were assessed via survey items administered before (pre-test) and after (post-test) viewing the material. No statistically significant differences were seen in changes of intention to vaccinate between groups (N = 1294). However, 16% of all (tailored and untailored combined) participants increased in their intention to vaccinate, while 7% decreased in intention. Overall 72% of participants had high intentions to vaccinate, yet far fewer actually received a vaccine dose. The current study explores implications of the demonstrated intention-behavior gap. As such, it presents opportunities to improve future interventions-specifically those that employ tailored messaging.

Development and Verification of Prognostic Nomogram for Penile Cancer Based on the SEER Database

Aim

We aimed to establish a prognostic nomogram for penile cancer (PC) patients based on the Surveillance, Epidemiology, and End Results Program (SEER) database.

Methods

Data from 1643 patients between 2010 and 2015 were downloaded and extracted from the SEER database. They were randomly divided into the development group (70%) and the verification group (30%), and then, univariate and multivariate Cox proportional hazards regression, respectively, was used to explore the possible risk factors of PC. The factors significantly related to overall survival (OS) and cancer-specific survival (CSS) were used to establish the nomogram, which was assessed via the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve. An internal validation was conducted to test the accuracy and effectiveness of the nomogram. Kaplan–Meier calculation was used to predict the further OS and CSS status of these patients.

Results

On multivariate Cox proportional hazards regression, the independent prognostic risk factors associated with OS were age, race, marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type, with a moderate C-index of 0.737 (95% confidence interval (CI): 0.713–0.760) and 0.766 (95% CI: 0.731–0.801) in the development and verification groups, respectively. The areas under the ROC (AUC) of 3- and 5-year OS were 0.749 and 0.770, respectively. While marital status, N/M stage, surgery, surgery of lymph nodes, and histologic type were significantly linked to PC patients' CSS, which have better C-index of 0.802 (95% confidence interval (CI): 0.771–0.833) and 0.82 (95% CI: 0.775–0.865) in the development and verification groups, and the AUC of 3- and 5-year CSS were 0.766 and 0.787. Both of the survival calibration curves of 3- and 5-year OS and CSS brought out a high consistency.

Conclusion

Our study produced a satisfactory nomogram revealing the survival of PC patients, which could be helpful for clinicians to assess the situation of PC patients and to implement further treatment.

Promoting HPV vaccination among Latinx: an application of the extended parallel processing model

Vaccine hesitancy is a substantial barrier to increasing HPV vaccination rates among Latinx in the US who experience disproportional rates of HPV-related cancers. The current research tests the effectiveness of culturally-targeted, fear-appeal messages designed using the Extended Parallel Processing Model (EPPM). We compared differences among Latinx young adults and parents of adolescents of the effectiveness of messages that highlight HPV-related cancers, genital warts, or a control condition to promote online information seeking about the HPV vaccine-a known precursor to vaccination intention. Results found messages containing EPPM messaging elements produced significantly higher self-reported intention to seek information about HPV vaccines in comparison to a control message group. However, participants who received control messages had the highest percentage of hyperlink clicks to more information about HPV (a novel measure of information seeking). Findings suggest that fear appeals may be effective for promoting information seeking about HPV vaccination, which in turn could increase vaccine utilization, among Latinx participants. Clinical trial registration number (NCT05206669) retrospectively registered January 25, 2022.

Testing Messages on Facebook to Promote Use of an HPV Educational Web-Intervention

In the US, the human papillomavirus (HPV) vaccine remains underutilized leading to disparities in HPV-related diseases. Latinx have some of the highest rates of cancer caused by HPV. In a previous study, we developed a tailored-messaging based online educational intervention (CHICOS) that was found to increase HPV vaccination intention among Latinx participants. The current research uses Facebook Advertising to test the comparative effectiveness of messages designed using the Extended Parallel Processing Model (EPPM) to promote the use of CHICOS among Latinx young adults and parents of adolescents. We also looked at differences in the effectiveness of messages that highlighted HPV-related cancers, genital warts, or a control condition as well as differences in Spanish vs. English messages. Results found Latinx young adults and parents, were more likely to click on Facebook Advertisements containing messages in Spanish and those that mention cancer risks pertinent to this population compared to those in English or messages that discuss genital warts. Thus, findings suggest that Facebook Advertising has the potential to be a useful tool for motivating information seeking online about HPV vaccination.

Racial Differences in Incident Genitourinary Cancer Cases Captured in the National Cancer Database

Background and Objectives: The National Cancer Database (NCDB) captures nearly 70% of all new cancer diagnoses in the United States, but there exists significant variation in this capture rate based on primary tumor location and other patient demographic factors. Prostate cancer has the lowest coverage rate of all major cancers, and other genitourinary malignancies likewise fall below the average NCDB case coverage rate. We aimed to explore NCDB coverage rates for patients with genitourinary cancers as a function of race. Materials and Methods: We compared the incidence of cancer cases in the NCDB with contemporary United States Cancer Statistics data. Results: Across all malignancies, American Indian/Alaskan Natives subjects demonstrated the lowest capture rates, and Asian/Pacific Islander subjects exhibited the second-lowest capture rates. Between White and Black subjects, capture rates were significantly higher for White subjects overall and for prostate cancer and kidney cancer in White males, but significantly higher for bladder cancer in Black versus White females. No significant differences were observed in coverage rates for kidney cancer in females, bladder cancer in males, penile cancer, or testicular cancer in White versus Black patients. Conclusions: Differential access to Commission on Cancer-accredited treatment facilities for racial minorities with genitourinary cancer constitutes a unique avenue for health equity research.

Disparities in HPV knowledge by race/ethnicity and socioeconomic position: Trusted sources for the dissemination of HPV information

PURPOSE

To examine the differences in HPV and HPV vaccine awareness, knowledge, and beliefs by race/ethnicity and socioeconomic position (SEP) among a national sample of non-Hispanic whites (NH-Whites), non-Hispanic Blacks (NH-Blacks), and Hispanics in the United States. We also examine differences in trusted health information sources by race/ethnicity and SEP.

METHODS

Data were obtained from the Health Information National Trends Survey, Cycle 1, conducted from January to April 2017. Descriptive statistics, bivariate analyses, multivariate logistic regression, and listwise deletion were used to examine HPV and HPV vaccine awareness and knowledge-related items, and trust in health information sources among NH-Whites, NH-Blacks, and Hispanics 18-49 years old.

RESULTS

HPV vaccine awareness was moderate with no significant differences across racial/ethnic groups. NH-Whites had significantly higher knowledge that HPV causes cervical cancer than NH-Blacks and Hispanics (p < 0.001). High SEP NH-Blacks (OR = 0.42, 95% CI = [0.24-0.73], p = 0.002]) and Hispanics (OR = 0.49, 95% CI = [0.31-0.79, p = 0.003]) had lower odds of knowing HPV causes a sexually transmitted disease than their white counterparts. Low SEP NH-Blacks (OR = 11.03, 95% CI = [3.05-39.86, p < 0.001]) had 11 times the odds of ever hearing about the HPV vaccine than low SEP NH-Whites. NH-Blacks had twice the odds of trusting health information from television (OR = 2.39, 95% CI = [1.52-3.78]. p < 0.001), and almost six times the odds of trusting health information from religious organizations than low SEP NH-Whites (OR = 5.76, 95% CI = [2.02-16.44, p < 0.001]).

CONCLUSION

Tailored communication strategies may address the low HPV knowledge among NH-Blacks and Hispanics from high and low SEP.

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.

Mutational landscape of penile squamous cell carcinoma in a Chinese population

Penile squamous cell carcinoma (PSCC) is a malignancy that affects the skin and tissues of the penis, but the knowledge of pathogenesis and carcinogenesis is limited. Here, we characterize the PSCC genomic landscape using whole-exome sequencing. Of the 30 paired blood and tumor samples, we identified recurrent mutations in 11 genes; confirmed previous findings for FAT1 (4/30), HRAS (4/30), NOTCH1 (4/30), TP53 (3/30) and PIK3CA (3/30); and revealed novel candidate driver genes [CASP8 (4/30), SLITRK2 (3/30), FLG (3/30) and TRRAP (3/30)]. Our in vitro experiments suggested CASP8 was involved in mediating TRAIL-induced apoptosis of penile cancer cell lines. We also observed the frequently altered pathways for potential therapeutic implications: alterations in the Notch (30% of sample altered), RTK-RAS (26.7% altered) and Hippo (23.3% altered) pathways accounted for over 50% of tumors. The frequently altered genes (>10%) in these pathways were proved to be expressed in penile tumors by immunohistochemistry assay. These findings provide new insight into the mutational and pathway landscapes of PSCC and suggest potential novel therapeutic opportunities for this malignancy.

Disparities in human papillomavirus-related cancer incidence and survival among human immunodeficiency virus-infected Hispanics living in the United States

BACKGROUND

Human papillomavirus (HPV) causes 10% of cancers among human immunodeficiency virus (HIV)-infected people in the United States. Because Hispanics are disproportionally affected by the HIV epidemic and by infection-related cancers, this study compared incidence rates for HPV-related cancers and survival between Hispanics and non-Hispanic whites (NHWs) and non-Hispanic blacks (NHBs) in the HIV-infected US population.

METHODS

Based on data from the HIV/AIDS Cancer Match Study, standardized incidence ratios (SIRs) were used to estimate cancer risk in HIV-infected Hispanics and the general US Hispanic population. Among HIV-infected people, cancer rates were compared with incidence rate ratios (IRRs), and survival was compared with hazard ratios between Hispanics and NHWs and NHBs.

RESULTS

Five hundred two HPV-related cancers occurred in 864,067 person-years of follow-up among HIV-infected Hispanics. Except for oropharyngeal cancer, the risk of HPV-related cancers was higher among HIV-infected Hispanics than in the general population (SIR range, 3.59 [cervical cancer] to 18.7 [anal cancer in men]). Among HIV-infected females, Hispanics had higher cervical cancer rates than NHWs (IRR, 1.70; 95% confidence interval [CI], 1.19-2.43) but lower vulvar cancer rates than NHWs (IRR, 0.40; 95% CI, 0.24-0.67) and NHBs (IRR, 0.62; 95% CI, 0.41-0.95). Among HIV-infected males, Hispanics had higher penile cancer rates than NHWs (IRR, 2.60; 95% CI, 1.36-4.96) but lower anal cancer rates than NHWs (IRR, 0.54; 95% CI, 0.46-0.63) and NHBs (IRR, 0.65; 95% CI, 0.56-0.77). Among HIV-infected Hispanics, 5-year survival was greater than 50% across HPV-related cancer types, with no major differences by racial/ethnic group.

CONCLUSIONS

HIV-infected Hispanics have an elevated risk for HPV-related cancers. Similarly to the general population, HIV-infected Hispanics have higher rates of cervical and penile cancer than NHWs and NHBs. HPV vaccination should be promoted among HIV-infected individuals to reduce the burden of HPV-related cancers.