Analysis of Suicide Risk in Patients with Penile Cancer and Review of the Literature

doi:10.1016/j.clgc.2017.09.011

Clinical Genitourinary Cancer

Volume 16, Issue 2, April 2018, Pages e257-e261

https://doi.org/10.1016/j.clgc.2017.09.011 Get rights and content

Abstract

The treatment for penile cancer has been shown to cause harmful psychiatric symptoms as well as have detrimental effects on well-being. In the past several years, alternatives to total or partial penectomy have emerged, such as chemotherapy, radiation, penile sparing, and laser ablation therapies. A more specific breakdown for penile cancer is in order as the therapy has the potential for life changing surgery. We examined the Surveillance, Epidemiology, and End Results (SEER) database (1973-2013), comprising 28% of the United States population. International Classification of Diseases, Tenth revision codes C60.8-C60.9 and the International Classification of Diseases-Oncology codes 8010/2, 8010/3, 8051/2, 8051/3, 8052/2, 8052/3, 8070/2, 8070/3-8072/3, 8074/3, 8076/3, and 8083/3-8084/3 were used. Age, race, marital status, and clinicopathologic variables were studied. We used contingency tables of suicide rates; mid-P exact test was used for analysis. There were 13 suicides noted in 6155 patients with squamous cell carcinoma of the penis. All patients that committed suicide had undergone a surgical intervention. Certainly, penile cancer after treatment has a powerful effect on quality of life as increased depression and sexual anxiety have been documented in postoperative patients. This is in contrast to the observed suicide rate. Despite the reported negative psychological effects in patients with penile cancer, suicide rates are among the lowest of all urologic malignancies.

Introduction

Penile cancer is one of the more uncommon urologic cancers. The incidence in Europe and the United States (US) is close to 1 in 100,000 men,1, 2 whereas it represents 10% to 20% of malignancy in men in Africa, Asia, and South America.³ Squamous cell carcinoma makes up > 95% of penile cancers, with the most common risk factors being human papillomavirus-16, human papillomavirus-18, phimosis, smoking, and lower socio-economic status.2, 4 The average age of diagnosis is 60 years, and the malignancy is more likely to be seen in men that are not married (odds ratio, 2.5).1, 5 The impact of penile cancer has been shown to cause significant psychological/psychiatric impact.

The treatment for penile cancer varies significantly depending on cancer stage and has been shown to cause harmful psychiatric symptoms in approximately 50% of patients as well as to have detrimental effects on well-being in up to 40% of patients.² More aggressive treatments, such as a partial penectomy, have been shown to cause anxiety in 31% to 58% of patients and depression in 39% of patients,6, 7 with significantly higher rates of anxiety in patients treated with a total penectomy.⁸ Much of these psychological/psychiatric effects are thought to be secondary to the devastating effect on a man’s self-image and sexual function.7, 9 For that reason, modalities such as penile-sparing surgical approaches, chemotherapy/radiation protocols, and laser ablative surgeries have been investigated as options to sexuality and health-related quality of life (HRQOL).9, 10, 11

Approximately 70% of suicides in the elderly (> 60 years old) are attributed to physical illness and malignancy.¹² We sought to investigate the risk of suicide in patients with penile cancer.

Section snippets

Data Sources

Patients with penile cancer were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The SEER database reports cancer-specific outcomes from specific geographic areas representing 28% of the US population.¹³ The study cohort consisted of patients from all 18 registries comprising SEER from 1973 through 2013. Comparisons with the general US population were based on data from the Centers for Disease Control and Prevention’s National Center for Injury Prevention and

Results

There were 13 suicides out of 6155 patients with penile cancer (SMR, 1.58; 95% confidence interval, 1.18-2.11) (Table 1). Of the 6155 patients with penile cancer, 5569 underwent surgical treatment for their disease. A total of 593 patients chose to undergo adjuvant or solitary radiation therapy. All 13 suicides recorded were among those who had undergo a surgical intervention (partial penectomy, total penectomy, etc) and 1 who had undergone adjuvant radiation. The median overall survival for

Discussion

Although more prevalent in underdeveloped countries, penile cancer is a rare urologic disease in the US and European countries. Analysis of the SEER database from 1998 to 2003 found 4967 cases of penile cancer with an incidence of 0.81 per 100,000 white males and 0.82 per 100,000 African American males.¹¹ Surgical treatment of penile cancer causes harmful psychiatric symptoms in approximately 50% of patients and has detrimental effects on well-being in up to 40% of patients.² Varying treatment

Conclusion

Although the literature reports mixed effects on men’s HRQOL and sexual health, the majority of studies analyzing those who underwent partial or total penectomy reported significant increases in anxiety and depression and significant decreases in sexual health. Aside from prostate cancer, this topic has arguably been investigated more thoroughly in penile cancer than any other urologic cancer. In our retrospective analysis, all 13 patients had undergone some form of surgical intervention of

Disclosure

The authors have stated that they have no conflicts of interest.

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However, penile cancer of any extent is not without its own risk. One SEER analysis of 6,155 patients with penile cancer found a suicide risk of 0.2%, all in men who had undergone a surgical intervention [26]. Early referral to a Supportive Care service is crucial for this patient population.
Patient reports of their symptom burden (i.e., patient-reported outcomes or PROs) have been shown to direct clinicians’ ability to personalize care and improve outcomes. A disciplined assessment of PRO in the population of patients with advanced penile cancer (PeCa) has not previously been undertaken. Our center leveraged a significant cadre of patients with PeCa and a significant experience with a well-established PRO: the Edmonton Symptom Assessment Scale (ESAS).
After IRB approval, we screened ESAS surveys of 14,781 patients completed between February 2017 and February 2021; these were collected in the Supportive Care and Radiation Oncology clinics. Of these, those with PeCa were divided into 3 cohorts: (A) Those after any partial penectomy procedure without lymph node dissection (LND); (B) Those after partial penectomy procedure with LND; and (C) Those after total penectomy and LND. Patients with recurrent disease were analyzed separately (D). ESAS scores were collated and compared both by individual symptom and cumulatively.
Twenty-two PeCa patients completed 122 ESAS surveys in this time and are included in this analysis: a median of 4 ESAS surveys (mean = 5, range = 1–19) were completed by each patient. The symptom with the highest median ESAS score was Tiredness (3.00). Patients with recurrent disease had the highest cumulative symptom score (median score = 30). Patients after total penectomy with LND had a higher cumulative symptom score (14.4) than those with partial penectomy and LND (7.9). Patients with partial penectomy without LND had a cumulative score of 22.
PROs provide an insight into the morbidity of therapies for advanced PeCa, and the most symptoms are reported by patients with recurrent disease.
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In line with the proposed research objectives, contingency tables are then constructed to analyse the relationship between qualitative attributes of which at least one is of a multiple nature (Varvazovska and Prasilova, 2015). This method is commonly used in a wide range of fields, such as medicine, transport, and even to address socio-economic issues (Simpson et al., 2018; Álvarez de Toledo et al., 2018; Zámková et al., 2019; Awuah and Ogbonnaya, 2020). In the context of waste, Virlanuta et al. (2020) employ contingency tables to identify the influence of very disparate characteristics such as education level, income and age on the degree of selective waste collection, finding a significant relationship only with education and age.
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To determine the LRR and PROs after MMS for male genital skin cancers.
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A total of 119 skin cancers in 108 patients were removed with MMS. Tumors were located on the penis (90/119) and scrotum (29/119). Diagnoses included squamous cell carcinoma in situ (n = 71), invasive squamous cell carcinoma (n = 32), extramammary Paget disease (n = 13), melanoma (n = 2), and basal cell carcinoma (n = 1). The LRR was 0.84% (1/119), with a mean follow-up time of 3.25 years (median, 2.36 years). The majority of survey respondents reported no changes in urinary (66%) or sexual functioning (57.5%) after surgery.
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ReviewAnalysis of Suicide Risk in Patients with Penile Cancer and Review of the Literature

Abstract

Introduction

Section snippets

Data Sources

Results

Discussion

Conclusion

Disclosure

Urology

J Urol

J Urol

J Urol

Burden of invasive squamous cell carcinoma of the penis in the United States, 1998-2003

Cancer

Identifying the needs of penile cancer sufferers: a systematic review of the quality of life, psychosexual and psychosocial literature in penile cancer

BMC Urol

Management of penile cancer

J Surg Oncol

Human papillomavirus prevalence and type distribution in penile carcinoma

J Clin Pathol

Penile cancer: importance of circumcision, human papillomavirus and smoking in in situ and invasive disease

Int J Cancer

Review
Analysis of Suicide Risk in Patients with Penile Cancer and Review of the Literature