Original article
Disparity between pre-existing management of penile cancer and NCCN guidelines

https://doi.org/10.1016/j.urolonc.2017.03.002Get rights and content

Highlights

  • Primary tumor management already closely following NCCN guidelines.

  • Regional lymph node management differed from subsequently introduced guidelines.

  • Patients with lymph node metastases who received dissection increased over time.

  • Patients more likely to undergo regional lymph node dissection at academic center.

Abstract

Objective

To determine the locoregional management of penile cancer before the introduction of NCCN guidelines and how much shift in practice patterns is required to meet the guidelines.

Methods

The National Cancer Data Base was queried to identify 6,396 patients with squamous cell carcinoma of the penis diagnosed between 2004 and 2013. The cohort was divided into management groups based on the NCCN guidelines: cTa and cTis (cTa/is), pT1 low grade (T1LG), pT1 high grade (T1HG), and pT2 or greater (T234). These groups were analyzed to determine if management of locoregional disease complies with the 2016 NCCN guidelines and logistic regression analyses were performed to determine factors associated with adherence.

Results

Nationwide management of the primary tumor closely follows the NCCN guidelines, with 96.9% adherence for cTa/is, 91.4% for T1LG, and 94.2% for T234. Management of regional lymph nodes (LNs) was inadequate with only 62.9% of patients with clinical N1 or N2 disease undergoing regional LN dissection (LND). The percentage of patients with known LN metastases who received regional LND increased over time (46.2% in 2004 to 69.4% in 2013, P = 0.034). Patients treated at community cancer programs (odds ratio [OR] = 0.26, 95% CI: 0.19–0.35), comprehensive community cancer programs (OR = 0.34, 95% CI: 0.29–0.41), and integrated network cancer programs (OR = 0.36, 95% CI: 0.25–0.52) were significantly less likely to receive LND compared with patients treated at academic comprehensive cancer programs.

Conclusions

Before the introduction of NCCN guidelines, national practice patterns for the management of the primary tumor were consistent with the recommendations. However, the management of regional LNs deviated from the guidelines, reflecting an area for improvement.

Introduction

Penile cancer is a rare malignancy, with an incidence of 0.6 per 100,000 in the United States [1], [2], accounting for an estimated 0.2% of malignancies in men [3]. The mortality rate is 0.15 per 100,000 in the United States and is higher in African American men compared with that in whites [1], [2], [4]. Historically, total or partial penectomy with a 2-cm margin was the gold standard of treatment. Recent studies have shown that conservative surgery and smaller surgical margins are oncologically safe, and that local recurrence does not affect survival [5], [6], [7], [8], [9], [10]. Additionally, penile-sparing surgery (PSS) offers better cosmetic results, urinary function, and quality of life than total penile amputation [6], [7], [9], [11], [12]. In 2013, the National Comprehensive Cancer Network (NCCN) created guidelines for the management of penile cancer, which have since been updated in 2016 [13], [14]. These guidelines include the recommendation of organ-sparing surgery for patients with cTis, cTa, and pT1 disease as defined by the 2010 TNM clinical and pathological classification system [13], [14], [15]. For tumors that are T2 or greater, partial or total penectomy is still the recommended therapy [14]. In addition, radiotherapy is an option for stage T1–T4 tumors and chemoradiotherapy may be used for T1b–T4 tumors [14].

Inguinal lymph node (LN) involvement is the most important prognostic factor in penile cancer [16]. The number of positive LNs, the presence of extranodal extension, and the pelvic LN involvement have all been associated with worse 5-year cancer-specific survival [17]. Patients without palpable lymphadenopathy who undergo inguinal lymph node dissection have improved overall survival, showing a benefit for immediate resection of clinically occult LN metastases [16], [18], [19]. Additionally, survival is improved in patients with unilateral LN metastases who undergo bilateral pelvic lymph node dissection [20]. The 2016 NCCN guidelines provide recommendations suggesting which patients should undergo LN surveillance, inguinal lymph node dissection, or pelvic lymph node dissection [14]. Despite this, one previous population-based study using the SEER database demonstrated an inadequate number of LNs removed in patients undergoing lymph node dissection (LND) for penile cancer and showed better cause-specific survival in patients who underwent more extensive LND [21].

Previous studies have documented the use of conservative surgery at tertiary referral centers [22]. However, the use of PSS and LND nationwide and adherence to NCCN guidelines are largely unknown. The aim of the present study was to use the National Cancer Data Base (NCDB) to determine how closely management of the primary site and regional LN metastases in patients with penile cancer aligned with the subsequently introduced NCCN guidelines.

Section snippets

Materials and methods

The NCDB is a collaboration between the Commission on Cancer of the American College of Surgeons and the American Cancer Society. We included all penile squamous cell carcinomas (SCC) from 2004 to 2013 using specific codes for primary site (ICD code C60) and histological subtype (ICD code 807). Only patients with clinical or pathologic AJCC M0 disease and patients with penile SCC confirmed on histology were included. Patients were excluded if their diagnosis was determined at the reporting

Results

We identified 6,396 patients with penile SCC diagnosed between 2004 and 2013. The median age was 65 (range: 54–75) years, and most patients were white (73.9%), had a Charlson-Deyo score of 0 (73.3%), were insured by Medicaid or Medicare (56.5%), and were treated at a metropolitan facility (80.5%) (Table 1). The tumors were most commonly pathologic T1 (29.5%) and clinical N0 (61.1%) (Table 1).

NCCN guidelines recommend that cTa/is penile cancer be treated with a penile-sparing approach, and our

Comment

Penile cancer is a very rare malignancy with the first national guidelines for disease management published in 2013. Previous studies have examined the use of penile-sparing techniques over the past few decades and have analyzed the rates of LND. Our goal was to use a large national patient cohort to determine how penile cancer was managed before the introduction of NCCN guidelines and how much shift in practice patterns is required to meet the guidelines.

Our study showed that national surgical

Conclusion

Our study uses a large national patient cohort to examine locoregional management of penile cancer. National practice patterns are consistent with the NCCN recommendations for treatment of the primary lesion. However, we identified potential deviation from the guidelines pertaining to the management of regional LNs, which can serve as targets for knowledge transfer initiatives.

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