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Global Burden of Penile Cancer: A Review of Health Disparities for a Rare Disease - Beyond the Abstract

Penile cancer, primarily squamous cell carcinoma (SCC), presents a rare but aggressive malignancy, with an incidence of more than 2000 new cases and an estimated 470 deaths in the United States in 2023.1 Prior literature suggests that social determinants of health including environmental exposures, lifestyle, obesity, education, and less access to care are associated with an increased risk of cancer in general.2 This review explores the intersectionality of race, ethnicity, and socioeconomic status on penile cancer incidence and outcomes on a global scale.3

We reviewed all available contemporary studies identifying disparities in penile cancer published before February 1st, 2024. When reviewing the literature out of Europe, both lower education and disposable income had a higher risk of invasive penile cancer often due to delayed diagnosis. Single men were also at increased risk for both invasive cancer and carcinoma in situ. In contrast, men with higher education were more likely to be diagnosed with non-invasive cancers.4 Delayed diagnosis was often linked to patient embarrassment which could contribute to more advanced disease.5

In the United States, the mortality rate was seen as associated with age and was higher in the Southern and impoverished regions compared to those living in Western regions. Mortality was also highest in Blacks compared to Whites and Asian/Pacific Islanders and Hispanics compared to non-Hispanics.6 Puerto Rican men have significantly higher penile cancer mortality compared to other U.S. racial groups, with socioeconomic deprivation, particularly lower education, contributing to higher incidence.7 Studies using data from the National Cancer Database revealed that lower socioeconomic status, lack of insurance, and racial disparities, especially among Black and Hispanic men, were linked to worse outcomes, higher stage at diagnosis, and lower survival rates, underscoring the role of social determinants in penile cancer prognosis.8-10

In Brazil, multiple factors contributed to the high rates of penile cancer, including sexual practices, low education, poor hygiene, smoking, and phimosis. Socioeconomic factors, such as low income, poor access to healthcare, and lack of education, were key contributors to late diagnosis.11 2 Additional studies reinforced these findings, with penile cancer being more prevalent in Brazil’s poorer northern regions.12-14 Similar regional disparities were observed in Costa Rica, where there were higher rates of penile cancer in impoverished areas with higher exposure to occupational and environmental pesticides.15

In a retrospective cohort study comparing penile SCC cases from Mozambique (high HPV and HIV prevalence) and Spain (low prevalence of both), the former had a significantly higher percentage of HPV-associated tumors.16 In Kenya, penile cancer was rare, mainly affecting uncircumcised populations, and showing a higher incidence of well-differentiated SCC.17 In China, between 2005-2015, it is estimated that 65% of new cancer cases at HPV-susceptible sites were HPV-attributable, with cervical cancer leading, followed by anal, oral cavity, penile, and other cancers.18

In conclusion, urologists must understand and address these disparities through targeted interventions, including education on risk factors and HPV vaccination. In the United States specifically, physicians should be aware of the racial and racial disparities that exist among patients with penile cancer. Further research focusing on histological and genetic profiles, particularly in minority and marginalized populations, is warranted to develop effective prevention and management strategies.

Written by: Vanessa Ogbuji, Irasema Concepcion Paster, and Juan Chipollini

Department of Urology, The University of Arizona, Tucson, AZ

References:

  1. Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. Jan 2023;73(1):17-48. doi:10.3322/caac.21763
  2. Afshar N, English DR, Milne RL. Factors Explaining Socio-Economic Inequalities in Cancer Survival: A Systematic Review. Cancer Control. Jan-Dec 2021;28:10732748211011956. doi:10.1177/10732748211011956
  3. Ogbuji V, Gomez DM, Paster IC, et al. Global burden of penile cancer: A review of health disparities for a rare disease. Urology. Sep 19, 2024;doi:10.1016/j.urology.2024.09.029
  4. Torbrand C, Wigertz A, Drevin L, et al. Socioeconomic factors and penile cancer risk and mortality; a population-based study. BJU Int. Jul 04 2016;doi:10.1111/bju.13534
  5. Skeppner E, Andersson SO, Johansson JE, Windahl T. Initial symptoms and delay in patients with penile carcinoma. Scand J Urol Nephrol. Oct 2012;46(5):319-25. doi:10.3109/00365599.2012.677473
  6. Hernandez BY, Barnholtz-Sloan J, German RR, et al. Burden of invasive squamous cell carcinoma of the penis in the United States, 1998-2003. Cancer. Nov 15, 2008;113(10 Suppl):2883-91. doi:10.1002/cncr.23743
  7. Colón-López V, Ortiz AP, Soto-Salgado M, et al. Penile cancer disparities in Puerto Rican men as compared to the United States population. Int Braz J Urol. Nov-Dec 2012;38(6):728-38. doi:10.1590/1677-553820133806728
  8. Attalla K, Paulucci DJ, Blum K, et al. Demographic and socioeconomic predictors of treatment delays, pathologic stage, and survival among patients with penile cancer: A report from the National Cancer Database. Urol Oncol. Jan 2018;36(1):14.e17-14.e24. doi:10.1016/j.urolonc.2017.09.014
  9. Ritch CR, Soodana-Prakash N, Pavan N, et al. Racial disparity and survival outcomes between African-American and Caucasian American men with penile cancer. BJU Int. May 2018;121(5):758-763. doi:10.1111/bju.14110
  10. Sharma P, Ashouri K, Zargar-Shoshtari K, Luchey AM, Spiess PE. Racial and economic disparities in the treatment of penile squamous cell carcinoma: Results from the National Cancer Database. Urol Oncol. Mar 2016;34(3):122 e9-15. doi:10.1016/j.urolonc.2015.10.001
  11. Teixeira Júnior AAL, da Costa Melo SP, Pinho JD, et al. A comprehensive analysis of penile cancer in the region with the highest worldwide incidence reveals new insights into the disease. BMC Cancer. Oct 15 2022;22(1):1063. doi:10.1186/s12885-022-10127-z
  12. de Sousa ID, Vidal FC, Branco Vidal JP, de Mello GC, do Desterro Soares Brandão Nascimento M, Brito LM. Prevalence of human papillomavirus in penile malignant tumors: viral genotyping and clinical aspects. BMC Urol. Feb 24 2015;15(1):13. doi:10.1186/s12894-015-0007-8
  13. Martins FE, Rodrigues RN, Lopes TM. Organ-preserving surgery for penile carcinoma. Adv Urol. 2008:634216. doi:10.1155/2008/634216
  14. Sudenga SL, Torres BN, Fulp WJ, et al. Country-specific HPV-related genital disease among men residing in Brazil, Mexico, and The United States: The HIM study. Int J Cancer. Jan 15 2017;140(2):337-345. doi:10.1002/ijc.30452
  15. Wesseling C, Antich D, Hogstedt C, Rodríguez AC, Ahlbom A. Geographical differences of cancer incidence in Costa Rica in relation to environmental and occupational pesticide exposure. Int J Epidemiol. Jun 1999;28(3):365-74. doi:10.1093/ije/28.3.365
  16. Manzotti C, Chulo L, López Del Campo R, et al. Penile Squamous Cell Carcinomas in Sub-Saharan Africa and Europe: Differential Etiopathogenesis. Cancers (Basel). Oct 27 2022;14(21)doi:10.3390/cancers14215284
  17. Magoha GA, Ngumi ZW. Cancer of the penis at Kenyatta National Hospital. East Afr Med J. Oct 2000;77(10):526-30. doi:10.4314/eamj.v77i10.46706
  18. Lu Y, Li P, Luo G, Liu D, Zou H. Cancer attributable to human papillomavirus infection in China: Burden and trends. Cancer. Aug 15 2020;126(16):3719-3732. doi:10.1002/cncr.32986
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