EAU and ASCO Release Collaborative Guidelines on Penile Cancer
Penile cancer is a rare disease with an incidence that is rising globally. Driven by a goal to offer clinicians and patients guidance on the management of this rare condition, ASCO collaborated with the European Association of Urology (EAU) to develop new guidelines on its diagnosis and treatment. A summary of the guidelines is available on the ASCO website, and the full guidelines will be published in European Urology.1
The guidelines were designed to be comprehensive, addressing every aspect of care from diagnosis to treatment and follow-up, with a patient-centered approach. Scott T. Tagawa, MD, MS, of Weill Cornell Medicine in New York, expressed gratitude to the patient representatives and advocates on the panel, noting they “played a major role in the overall content…and in shaping the guidelines.”
Scott T. Tagawa, MD, MS
The new guidelines were developed collaboratively by a panel with members from Europe, the United States, Canada, and South America. These experts reflect the many disciplines involved in the care of a patient with penile cancer, including urology, medical oncology, radiation oncology, pathology, and surgery.
“This is the first multicontinental guideline, and we hope to provide physicians all over the world [with] proper guidance in the management of this rare disease,” said Oscar R. Brouwer, MD, PhD, of the Netherlands Cancer Institute in Amsterdam.
Given the psychological impact and stigma of a penile cancer diagnosis and the potential implications of surgical treatment, the guidelines open with a strong recommendation that patients’ emotional, social, and physical needs “are discussed and addressed early in the patient pathway, through a holistic and multidisciplinary approach.”1 After discussing diagnosis and management, the guideline ends with a chapter dedicated to quality of life.
Dr. Tagawa noted that delays in diagnosis of penile cancer are common. Therefore, increasing awareness about the disease and its diagnosis are a priority. Human papillomavirus (HPV) is the main risk factor for penile cancer, as approximately half of cases are related to HPV.2 Accordingly, HPV testing is an important component of the pathologic workup.1
Challenges in Penile Cancer Treatment
Given the complexity of caring for patients with penile cancer, coupled with the rarity of the disease, centralization of care at a large-volume center with access to knowledge, expertise, and technology that may not be available elsewhere is recommended. However, even for specialized centers, the treatment of penile cancer presents challenges, as optimal treatments of advanced disease have not been identified, and outcomes remain poor. Progress in penile cancer treatment has been hampered by a lack of sufficient prospective trials, which are challenging to conduct given the small patient population. In these cases, the guidelines pull together available lower-level evidence to help inform recommendations.
“This is the first multicontinental guideline, and we hope to provide physicians all over the world [with] proper guidance in the management of this rare disease.”— Oscar R. Brouwer, MD, PhD
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The variety of available therapeutic options and the lack of standardized treatment approaches also point to a need for multidisciplinary care, noted Dr. Brouwer. “We have all these treatment modalities (surgery, chemotherapy, immune therapy, radiotherapy), but little is known about the optimal treatment order,” he commented. Consequently, Dr. Brouwer said the treatment decision “really needs to be discussed in a multidisciplinary tumor board with enough experience.”
Given the urgent need for more effective treatments of advanced penile cancer, efforts are underway to identify potential therapeutic targets. Although prospective trials in penile cancer have proven difficult to perform, basket trials are an alternative approach. For example, the U.S. National Cancer Institute’s ICONIC trial (ClinicalTrials.gov identifier NCT03866382) in patients with rare genitourinary tumors includes a penile cancer cohort. Additionally, experts have focused on collaborating to maximize research efforts, leading to the possibility of clinical trials specifically in penile cancer. “The collaborations that some of these genomic studies have needed by necessity [to get sufficient patient numbers] have led to therapeutic collaborations,” noted
Dr. Tagawa and Dr. Brouwer also hope that by bringing together experts from around the world, the guidelines may also spur new collaborative efforts to make additional progress in penile cancer treatment. “I hope these newly founded friendships might also fuel future collaborative research initiatives,” Dr. Brouwer said. He added that new treatments are needed to improve outcomes and quality of life for patients with penile cancer, and this can only be achieved by working together across specialties.
1. Brouwer OR, Albersen M, Parnham A, et al: Penile cancer: European Association of Urology–American Society of Clinical Oncology Collaborative Guidelines on Penile Cancer: 2023 update. Eur Urol. March 9, 2023 (early release online).
2. Olesen TB, Sand FL, Rasmussen CL, et al: Prevalence of human papillomavirus DNA and p16INK4a in penile cancer and penile intraepithelial neoplasia: A systematic review and meta-analysis. Lancet Oncol 20:145-158, 2019.
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