PCT Penile Conservative Therapy & Sexual Functions in Penile Cancers

1. PCTPenile Conservative Therapy &Sexual Functions in Penile Cancers Rajiv Sarin, Radiation Oncologist Tata Memorial Hospital ESTRO TMH EBM Course 2005

2. Penile cancers: The Facts • Though rare in west, high prevalence in some developing countries (Brazil, India etc) • Like cervical cancers, HPV is an important causative factor i.e. PREVENTABLE • Amenable for early diagnosis. • Glans infiltrate shaft  nodes. • In developing countries late presentation

3. Penile cancers: The Facts • No consensus regarding optimal management • Recent UK survey (Harden, Clin Oncol 2001): Irrespective of Stage • Most Urologist preferred penectomy • Most Clinical Oncologist preferred RT. • Most Literature reports describe treatment and disease control but no formal evaluation of sexual dysfunction. • No randomised trials ever conducted

4. Why PCT is not the standard of care in early penile cancer? BCT is the standard of care in Early Breast Cancer

5. Why PCT is not the standard of care in early penile cancer? • Common in developing countries and rare in the affluent western countries. • Doubtful patient compliance • Remembering non compliant patients for whom PCT failed and they died unnecessarily by not undergoing curative amputative surgery initially. • Partial Penectomy: Procedure quick- can be done by General Surgeons even at small places. Radiotherapy not in all centres, acute reactions, higher risk of failure • Urologists Prefer Penectomy • Publications Bias • Penectomy  Urology Jr. • PCT  Radiotherapy / Cancer Jr. No Advocates

6. Forms of PCT • Radiotherapy • External Beam RT • 50-55Gy in 3-4 weeks (accelerated) • 60Gy in 6 weeks • Brachytherapy • Interstitial Iridium-192 Implant • Surface Mould • Moh’s Microsurgical Technique • LASER Excision / Wide Excision

7. Advantages of RT • Organ preservation of penis, without compromising the local control or survival. • Retains erectile potency and sexual function. • Eliminates psychological distress.

8. Penile Conservation with Radiotherapy: At what cost?

9. Not just the cosmetic outcome, It is the function that matters Are functions retained with PCT?

10. Studies Assessing Quality of Life Opjordsmoen S et al • Sexuality in patients treated for penile cancer: patient’s experience and Doctor’s judgement. Br J of Urology (1994) 73, 554-560. • Retrospective study

11. TMH Prospective Study: Aims • Local control rate • Survival • To determine the psychosexual morbidity • Physical morbidity • Complications

12. Pre-RT Evaluation of Sexual Functions • Libido • Quality of erection • Frequency of intercourse • Sexual satisfaction

13. TMH Prospective study of PCT using accelerated External RT1996-2003

14. Penis wrapped in cellophane and taken out through central aperture + bolus Tele Cobalt Locally fabricated water filled Perspex box to hold penis (2 sizes) Dose and Treatment Delivery • Dose- 54-55Gy/3weeks • 3-3.3Gy/ Fraction • 23-33 days • Close follow up • 1-2 monthly - first year • 2-3 monthly-second yr • 3-6 monthly after three years.

15. Treatment and Acute Reactions • Accelerated five days per week regimen of either 55Gy/16# (n=9); 54Gy /18# (n=12 patients), or other regimens (n=2) • In all patients, acute radiation reactions over the glans and skin appeared 2-3 wks after starting RT and healed completely after a mean duration of 9 wks (range 3-28 wks) • The mean healing time of 12 wks (range 3-28) with the radiobiologically more intense regimen of 55Gy/ 16# used in the initial 9 patients was significantly reduced to 6 wks (3-14) after modifying the fractionation slightly to 54Gy /18# in the subsequent 12 patients (p=0.02). • Symptoms of mild radiation urethritis were observed in 15 patients which resolved within 1-3 wks and no patient required catheterization during / after RT.

16. Other Late sequelae of RT • Mild asymptomatic urethral maetus narrowing occurred in 2 men. • Post radiation hypopigmentation with or without mild telengiectasia in the irradiated skin and glans was observed in all patients on long term follow up. • All patients were well adapted in society and maintained their normal life style after treatment. • None of these men had any obvious symptoms of anxiety or depression.

17. TMH Prospective study of PCT: Results STAGE II Actuarial 5 year penile control rate with penile preservation was 33% after RT and 100% after salvage penectomy STAGE I Actuarial 5 year penile control rate with penile preservation was 92% after RT and 100% after salvage penectomy

18. Tata Memorial Hospital PCT Study Prospective evaluation of Sexual Functions * 5 patients who underwent penectomy for residual / recurrent disease not included. ** 1 patient had loss of erectile function before starting Radiotherapy ***2 patients with normal erection were not sexually active (single and advanced age).

19. Conclusion Radical radiotherapy is an effective means of achieving local tumor control and leads to preservation of a functioning penis. Surgery as salvage therapy after radical irradiation gives a high rate of long term survival in the early stage penile cancers.

20. Conclusion • It is unfortunate for men with early, radiocurable cancers subjected to unnecessary penectomy and hazardous for those with advanced cancers treated with primary radiotherapy. • A randomised trial is unlikely to be ever conducted and may be even considered unethical by some. • Thus, findings of our relatively small but prospective study evaluating tumour control and sexual functions could form the scientific basis for making treatment recommendations which would then need to be validated in larger prospective studies.

21. Conclusion • Radiotherapy is recommended for Stage-I cancers to avoid post penectomy sexual dysfunction and psychological morbidity but penectomy is often required for more advanced cancers. • Accelerated RT Regimen have more acute toxicity but acceptable late sequelae and excellent local control rates.

22. Partial Penectomy not affecting sexual quality of life! As hard to imagine as these flowers growing from the wall- Is it the truth!

23. Organ and Function Preservation