Expert highlights latest developments in penile cancer

Philippe E. Spiess, MD

Like other areas of urologic oncology, penile cancer is evolving in many ways. From new treatment methods to ongoing challenges, this year’s Society of Urologic Oncology Annual Meeting brought about many discussions revolving around this subspecialty. As the chair of the penile cancer session, Philippe E. Spiess, MD, MS, FACS, covered many of these topics, specifically diving into current clinical trials and cases he treated in his own practice. Spiess is a genitourinary oncologist and assistant chief of surgical services at the Moffitt Cancer Center in Tampa, Florida.

Could you provide a brief overview of the session and discuss some of the highlights?

Penile cancer is a rare cancer. Although, as urologic oncologists, we all see a few cases in our practices individually, I think, no question, there's a lot of heterogeneity in how penile cancer is managed across the United States. And actually, there'll be some data that will be highlighting that [in this meeting,] even among highly qualified and trained colleagues and SUO members. The session will be very educational, and it will really be focused in 3 parts. One is going to be an update related to an international trial taking place right now called the International Penile Advanced Cancer Trial, or the InPACT trial.¹ What we'll be presenting is the design of the study, what the study endpoints are, and what has been achieved in terms of accruals thus far. The study, hopefully, will be completing its accrual in about 3 years, and that will be presented by Dr. Juanita Crook. And then I will be moderating a case presentation session focusing on the management of complex cases including potential complications ensuing from them which will be highlighted in 2 specific cases of penile cancer from my practice that I've managed over a couple of years. The focus of that specific case presentation will be discussing the management of complications when you manage patients with penile cancer. That's one of the most challenging elements in caring for these patients. When patients get complications, it can be very, very challenging to optimize, to minimize the sequelae of the complications, and make sure they don't really increase in severity or impact on our patients. We have faculty participants from several specialties, 1 being a plastic surgeon. We're [also going to] have 3 individual surgeons discussing some of the things they do in their practices, and sharing their clinical pearls, which I think will be of great value.

The last session will be an update on systemic therapies for penile cancer. Again, just because it's a rare cancer, I think that session will be very informative for people in the audience in terms of what are the standards in chemotherapy, what's coming in terms of immunotherapies, and what's coming in terms of novel [types] of targeted therapies as well. I think that will be something which the audience will very much appreciate. It will definitely generate some thoughtful questions.

What are some current challenges in the surgical treatment of penile cancer? What is being done to overcome them?

The nature of the surgical management of penile cancer is that obviously it can be a very debilitating cancer for males and for their partners and families. And so, one of the important things is [that] we want to maintain, first and foremost, and optimize surgical outcomes in terms of cancer outcomes, in terms of survival, [and] in terms of control of the disease. But very importantly, associated with that is quality of life for patients. We see that a lot of the surgical management of the primary tumors of the penis, or of the areas where they [will] typically go to, which is the anal lymph nodes, can be very challenging in terms of risk of complications and how to manage them. I think there are a lot of opportunities to standardize these things. Hopefully we'll be able to do that through that session.

The other thing related to penile cancer, which can be challenging, is in the setting of advanced cancer. We still debate: What's the best sequence of treatment? Is it to give chemotherapy, for example, then do surgery? Or do surgery and then give chemotherapy? That's what [the] InPACT trial is specifically being designed to conduct and to answer.

Have there been any recent novel therapeutic approaches to penile cancer? Do you anticipate any in the next year or so?

There have been some advances in systemic therapies for penile cancer. We still debate, and there are some good data, that chemotherapy is not that effective for many patients with penile cancer. So, immunotherapies have emerged as an option, particularly in patients who are, for example, PDL-1-positive or patients who have a high tumor mutational burden. And we do have some published data on using agents like pembrolizumab [Keytruda], for example, in patients who are not candidates for chemotherapy or who fail chemotherapy. I think, also, there is some emerging data now [for] novel forms of immunotherapies related to tumor-infiltrating lymphocytes (TILs), [and] potentially even CAR T therapy, which could be used in combination with systemic therapies and immunotherapies in the future. Last, but not least, I think we're always trying to [find out] if there are specific actionable mutations that we can identify specific to penile cancer in both the HPV positive and the HPV negative cancers because those are very diverging in their pathophysiological pathways.

Reference

1. International penile advanced cancer trial (international rare cancers initiative study). ClinicalTrials.gov. (InPACT). Updated October 31, 2019. Accessed December 7, 2021. https://clinicaltrials.gov/ct2/show/NCT02305654