Urologic Oncology: Seminars and Original Investigations ] (2016) ∎∎∎–∎∎∎

Original article
15 Years of penile cancer management in the United States: An analysis
of the use of partial penectomy for localized disease and chemotherapy in
the metastatic setting
Matthew Mossanen, M.D.*, Sarah Holt, Ph.D., John L. Gore, M.D., M.S., Daniel W. Lin, M.D.,
Jonathan L. Wright, M.D., M.S.
Department of Urology, University of Washington School of Medicine, Seattle, WA
Received 20 March 2016; received in revised form 27 June 2016; accepted 29 June 2016

Abstract
Background: Penile cancer remains a rare disease in the United States, and its understanding may be limited by the uncommon nature of
the malignancy. We sought to describe recent penile cancer treatment patterns using the National Cancer Data Base.
Methods: A retrospective review of data obtained from the National Cancer Data Base from 1998 to 2012 was performed. We obtained
demographic information and therapeutic approaches within the following2 clinical scenarios: performance of partial penectomy for early
stage disease (clinical Ta–T2) and the use of chemotherapy for metastatic disease. Multivariate logistic analysis was performed.
Results: A total of 2,677 patients presented with early stage penile carcinoma. The proportion receiving partial penectomy increased from
74% in 1998 to 2000 to 80% in 2010 to 2012 (P o 0.001). Partial penectomy was more common in the elderly (age 4 80, odd ratios [OR]
¼ 1.53, 95% CI: 1.05–2.23), young (age o 50, OR ¼ 1.46, 95% CI: 1.02–2.07), and in African Americans (OR ¼ 1.45, 95% CI: 1.00–
2.12). Increasing tumor size was significantly associated with decreased likelihood of receiving partial penectomy. Of those presenting with
metastatic disease (n ¼ 819), use of chemotherapy increased over the time period from 39% receiving chemotherapy in 1998 to 2000 to
49% in 2010 to 2012 (P o 0.03). Patients least likely to receive chemotherapy were older and with higher Comorbidity score (both
P o 0.05), African American (OR ¼ 0.46, 95% CI: 0.30–0.73), and living Z50 miles from the nearest treatment hospital (OR ¼ 0.37,
95% CI: 0.25–0.55).
Conclusions: Penile-sparing surgery for early stage disease and the use of chemotherapy for metastatic disease are becoming more
commonly utilized over the past several years. Further work is needed to define clinical and nonclinical factors associated with the treatment.
r 2016 Elsevier Inc. All rights reserved.

Keywords: Penile cancer; National Cancer Data Base; Chemotherapy; Partial penectomy; United States

1. Introduction survival may be as low as 10% [3]. Owing to the clinical

Penile carcinoma (PC) is a rare disease in the United
States with approximately 1,500 new diagnoses and over
300 deaths annually [1]. PC often displays a propensity for
locoregional spread to lymph nodes and metastatic deposi-
tion to distant sites [2]. In fact, for those with advanced
disease already involving the pelvic lymph nodes, 5-year
Data provided by American College of Surgeons: National Cancer Data
Base.
*Corresponding author. Tel.: þ1-818-590-2441; fax: þ1-206-543-3272.
rarity of the disease, the ability to comprehensively study
PC in the United States is limited and most of the available
literature is based on small-sized, single-institution retro-
spective reviews. Thus, the aggressive clinical nature
combined with the rarity of the condition may contribute,
in part, to a lack of available data to study the disease.
Multiple management strategies are available for men
with PC. Increasingly, the surgical approach to the primary
tumor has focused on penile preservation advocating for
broader use of partial penectomy as opposed to radical

E-mail addresses: mnmoss@uw.edu, matthewmossanen@outlook.com

penectomy [4]. There are now increasing options for
(M. Mossanen) management of metastatic disease with the use of various

http://dx.doi.org/10.1016/j.urolonc.2016.06.019
1078-1439/r 2016 Elsevier Inc. All rights reserved.
2 M. Mossanen et al. / Urologic Oncology: Seminars and Original Investigations ] (2016) 1–7
chemotherapy regimens resulting in improved response
rates and survival [5]. Whether these strategies have been
adopted by the general urology practice in the United States
is unknown. To better understand the use of partial
penectomy and chemotherapy in PC, we used the data
provided by the National Cancer Data Base (NCDB).
2. Methods
2.1. Study sample
This is a retrospective review based on a cohort created
from the Commission on Cancer's NCDB from 1998 to 2012.
The sample is de-identified patient level data that are Health
Insurance Portability and Accountability Act compliant, thus
qualified for a waiver of institutional review board approval.
We analyzed patient characteristics, demographic informa-
tion, and therapeutic approaches within 2 clinical scenarios
—(1) use of partial penectomy for early stage (clinical Ta–T2
disease) and (2) use of chemotherapy for metastatic disease.
For Scenario 1, the inclusion criteria were cTa–T2 PC cases
with either partial or total penectomy (n ¼ 2,677). Patients
treated with no surgery (n ¼ 362), ablation (n ¼ 1,551), or
unknown surgery (n ¼ 65) were excluded, as were those with
no clinical stage reported. For Scenario 2, examining metastatic
PC cases, 37 cases with unknown chemotherapy treatment data
were excluded for a total of 817 cases in the analysis.
2.2. Outcome measures
For Scenario 1, the dependent variable was surgery type
(partial vs. total penectomy) with the primary independent
variable being year of diagnosis in categorical 3-year
increments (1998–2000, 2001–2003, 2004–2006, 2007–
2009, and 2010–2012). For Scenario 2, the dependent
variable was receipt of chemotherapy (yes vs. no) with
the primary independent variable being year of diagnosis in
same categorical format. Secondary independent variables
considered included age, race, insurance type, Charlson
Comorbidity score, stage (Ta/T1 vs. T2 for first part of
analysis only), clinical nodes, distance traveled to hospital
(o50 vs. 50þ miles), median income of patient's area of
residence, number of high school graduates in patient’s area
of residence, if facility was academic center, regional
location of facility, and urban/rural status of facility. Income
and education variables were estimated by matching the zip
code of the patient recorded at the time of diagnosis against
files derived from year 2000 US Census data. Tumor size
was included in the Scenario 1, but not for Scenario 2.
Tumor size was grouped into quartiles.
2.3. Statistical analysis
Descriptive statistics were calculated with univariate
associations between dependent variable (surgery type or
chemotherapy status) and patient characteristics assessed by
chi-square. In Scenario 1, multivariate logistic regression
models were constructed to identify factors independently
associated with partial penectomy. Only variables that were
significantly associated with the outcome in the univariate
setting were included in the multivariate model. Variables
included in the model were year of diagnosis, age, race,
academic center, insurance type, clinical T stage, and
clinical node status. Variables considered but not found to
appreciably alter risk estimates included distance, hospital
location variables, socioeconomic status (SES) variables,
and comorbidity scores. Stratified logistic models were
created by clinical T stage (Ta–T1 vs. T2). A propensity
score–adjusted model was also created for likelihood of
partial penectomy. Propensity scores were estimated using a
probit model with secondary covariates (age, race, Charlson
score, SES measures, facility type, insurance type, distance,
and urban/rural status) to predict a subject having partial
penectomy. The propensity score satisfied the balancing
property. Year of diagnosis, clinical stage, and nodal status
covariates were not included in the propensity score so that
we could independently assess their association with partial
penectomy. The estimates of the logistic model using the
propensity score as a covariate along with year of diagnosis
and clinical covariates did not substantially differ from the
logistic model containing all secondary covariates, thus the
nonpropensity score–matched model is presented to illus-
trate risk estimates across all covariates. In Scenario 2,
multivariate logistic regression models were constructed to
identify factors independently associated with chemother-
apy for patients with metastatic disease. Variables included
in the model were year of diagnosis, age, race, and distance
in miles between the patient's residence and the hospital that
reported the case, Charlson Comorbidity score, and clinical
node status. Variables considered but not found to appreci-
ably alter risk estimates included hospital location variables,
SES variables, and comorbidity scores. All statistical
analyses were conducted using Stata, version 13 (Stata,
Inc., College Station, TX).
3. Results
Table 1 shows demographic, clinical, and facility char-
acteristics stratified by the treatment parameters of the 2
analysis cohorts. From 1998 to 2010, a total of 2,677
patients who underwent surgery for early stage disease were
identified. The proportion receiving partial penectomy
increased from 74% in 1998 to 2000 to 80% in 2010 to
2012 (P o 0.001). Compared to those aged 50 to 59, partial
penectomy was more common in the old (age 4 80, odd
ratios [OR] ¼ 1.53, 95% CI: 1.05–2.23) and young
(age o 50, OR ¼ 1.46, 95% CI: 1.02–2.07). Treatment
at academic centers and those without insurance were less
likely to receive partial penectomy (both P o 0.01), as
were patients with cT2 and node-positive disease
 M. Mossanen et al. / Urologic Oncology: Seminars and Original Investigations ] (2016) 1–7 3

Table 1
Demographic, clinical, and treatment center characteristics of patients with clinical Ta/T1/T2 penile carcinoma treated with either partial or total penectomy

Category Total penectomy, N (%) Partial penectomy, N (%) Multivariate odds ratioa 95% CI

Total 581 (22) 2096 (78)

Year of diagnosis
1998–2000 108 (26) 306 (74) 1.00 Referent
2001–2003 91 (23) 307 (77) 1.20 0.86–1.69
2004–2006 95 (24) 306 (76) 1.16 0.83–1.63
2007–2009 133 (20) 545 (80) 1.67 1.22–2.27
2010–2012 154 (20) 632 (80) 1.74 1.23–2.36

Age
o50 19 (19) 80 (80) 1.46 1.02–2.07
50–59 120 (29) 299 (71) 1.00 Referent
60–69 150 (22) 539 (78) 1.15 0.84–1.58
70–79 145 (20) 583 (80) 1.14 0.81–1.61
80þ 83 (17) 416 (83) 1.53 1.05–2.23

Race
White 521 (22) 1819 (78) 1.00 Referent
Black 42 (20) 170 (80) 1.45 1.00–2.12
Asian 10 (16) 52 (84) 1.71 0.83–3.49
Other 5 (19) 22 (81) 1.44 0.51–4.09
Unknown 3 (8) 33 (92) 3.16 0.95–10.6

Insurance
Medicare 48 (29) 119 (71) 1.00 Referent
Private 160 (20) 622 (80) 1.06 0.81–1.38
Medicaid 280 (19) 1179 (81) 0.72 0.47–1.09
None/other 93 (35) 176 (65) 0.55 0.39–0.79

Median income (year 2000)

o$30,000 114 (24) 354 (76)
$30,000–$35,999 126 (23) 414 (77)
$36,000–$45,999 164 (21) 621 (79)
Z$46,000 152 (20) 622 (80)

Percent no high school degree (year 2000)

Z29% 135 (21) 507 (79)
20%–28.9% 162 (24) 503 (76)
14%–19.9% 136 (23) 453 (77)
o14% 123 (18) 548 (82)

Clinical T stage
Ta/T2 292 (18) 1349 (82) 1.00 Referent
T2 289 (28) 747 (72) 0.67 0.55–0.82

Tumor size
o15 mm 34 (11) 271 (13) 1.00 Referent
15–25 mm 51 (11) 208 (19) 1.02 0.63–1.63
25–39 mm 120 (19) 516 (25) 0.55 0.36–0.84
Z40 mm 237 (36) 426 (20) 0.25 0.17–0.38
Missing 139 (23) 475 (23) 0.43 0.29–0.66

Clinical nodes
Negative 397 (19) 1668 (81) 1.00 Referent
Positive 136 (38) 219 (62) 0.53 0.40–0.69
Unknown 48 (19) 209 (81) 1.30 0.91–1.84

Grade
Well differentiated 153 (21) 576 (79)
Moderate differentiated 236 (21) 903 (29)
Poorly/undifferentiated 138 (25) 414 (75)
Unknown 54 (21) 203 (79)
4 M. Mossanen et al. / Urologic Oncology: Seminars and Original Investigations ] (2016) 1–7
Table 1
Continued
Category Total penectomy, N (%) Partial penectomy, N (%) Multivariate odds ratioa 95% CI
Charlson/Dayo score
0 283 (20)
1 93 (21)
Z2 38 (23)
Missing 167 (25)
Distance from patient's residence to hospital reporting the case
o50 miles 452 (20)
Z50 miles 114 (28)
Unknown 14 (26)
Facility type
Community Cancer Program/Comprehensive 292 (19)
Community Cancer Program
Academic/Research program 289 (25)
a
Multivariate model includes only variables that were significantly associated with the outcome in univariate analysis.
(both P o 0.001). Tumor size was significantly associated
with receiving partial penectomy in the multivariate model
with decreasing likelihood for larger tumors. African-
American men also were more likely to undergo partial
penectomy.
Table 2 shows demographic, clinical, and treatment center
characteristics of patients with metastatic penile carcinoma
treated with or without chemotherapy. Of those presenting
with metastatic disease (n ¼ 819), the use of chemotherapy
increased over the time period from 39% receiving chemo-
therapy in 1998 to 2000 to 49% in 2010 to 2012 (P o 0.03).
Patients least likely to receive chemotherapy were older and
with higher Charlson Comorbidity score (both P o 0.05),
African American (OR ¼ 0.46, 95% CI: 0.30–0.73), and
those living Z50 miles from the nearest treatment hospital
(OR ¼ 0.37, 95% CI: 0.25–0.55). Multiagent chemotherapy
was used in 74% of patients.
4. Conclusions
In this work, we demonstrate the evolving landscape in
the management of PC over the past 10 years. Among our
findings, we have found an increased rate of utilization in
partial penectomy for early stage disease. Several factors
may account for this observation. Traditional approaches to
penile cancer have focused upon radical penectomy for
optimal oncologic control. However, recent data have
indicated that partial penectomy may obtain adequate local
control with comparable survival rates to radical penectomy
[6,7]. Organ-sparing approaches have been able to demon-
strate durable oncologic outcomes [7,8]. Tumor size was
associated with partial penectomy, and not surprisingly, we
found a decreased likelihood of partial penectomy for larger
tumors. Moreover, attention to the psychological morbidity
1101 (80)
359 (79)
128 (77)
508 (75)
1762 (80)
294 (72)
40 (74)
1248 (81) 1.00 Referent
848 (75) 0.77 0.62–0.96
of this operation has led to recognition of the compromised
sexual and urinary function as a result of this operation [9].
In fact, in a study of patients with penile cancer, as many as
23% of patients may be willing to accept decreased rates of
long-term survival in order to preserve sexual function [9].
A systematic review of patients with penile cancer found
that up to two-thirds of patients report a decline in sexual
function and nearly half of patients report psychiatric
symptoms such as anxiety and depression [10].
We also found that age was associated with the kind of
patients undergoing partial penectomy. Compared to those
aged 50–59, partial penectomy was more common in the
elderly (age 4 80) and young (age o 50). This may be due
to younger patients placing higher emphasis on sexual
function and being less willing to accept the consequences
to quality of life after total penectomy. Older patients who
are unable to tolerate more extirpative approaches such as a
total penectomy may be more appropriate candidates for
partial penectomy. African Americans were more likely to
undergo partial penectomy. Additional efforts are needed to
appreciate the effect of racial and ethnic factors in patient
preferences when considering management options. Treat-
ment at academic centers and those without insurance were
less likely to receive partial penectomy. One explanation for
this may be that individuals being sent to academic centers
are more likely to have cT2 disease, and that comfort with
total penectomy may be higher at medical centers with
dedicated oncologic specialists. Individuals without insur-
ance were also less likely to receive partial penectomy
highlighting potential issues with limited access to care. In
the future, focus on elucidating barriers to access to care
may help address this need.
Metastatic penile cancer is associated with poor survival
[4]. We found that older individuals and those with
increased comorbidity score were less likely to receive
 M. Mossanen et al. / Urologic Oncology: Seminars and Original Investigations ] (2016) 1–7 5

Table 2
Demographic, clinical, and treatment center characteristics of patients with metastatic penile carcinoma treated with or without chemotherapy

Category No chemotherapy, N (%) Chemotherapy, N (%) Multivariatea odds ratio 95% CI

Total 463 (57) 356 (43)

Year of diagnosis
1998–2000 72 (61) 46 (39) 1.00 Referent
2001–2003 92 (65) 50 (35) 0.92 0.49–1.71
2004–2006 70 (55) 58 (45) 1.76 0.69–4.548
2007–2009 105 (56) 82 (44) 1.48 0.60–3.70
2010–2012 125 (51) 120 (49) 1.86 0.75–4.59

Age
o50 48 (39) 74 (61) 1.00 Referent
50–59 93 (49) 97 (51) 0.67 0.41–1.10
60–69 118 (54) 102 (46) 0.54 0.34–0.88
70–79 123 (66) 64 (34) 0.30 0.18–0.49
80þ 81 (81) 19 (19) 0.12 0.06–0.24

Race
White 371 (55) 299 (45) 1.00 Referent
Black 76 (65) 41 (35) 0.46 0.30–0.73
Asian 6 (38) 10 (63) 1.74 0.59–5.17
Other 3 (75) 1 (25) 0.19 0.02–2.42
Unknown 7 (58) 5 (42) 0.80 0.24–2.63

Insurance
Medicare 244 (66) 127 (34)
Private 119 (51) 115 (49)
Medicaid 43 (48) 47 (52)
None/other 57 (46) 67 (54)

Median income (year 2000)

o$30,000 102 (59) 71 (41)
$30,000–$35,999 99 (57) 75 (42)
$36,000–$45,999 139 (60) 92 (40)
Z$46,000 108 (52) 99 (48)

Percent no high school degree (year 2000)

Z29% 120 (55) 98 (45)
20%–28.9% 127 (60) 85 (40)
14%–19.9% 105 (58) 76 (42)
o14% 96 (55) 78 (45)

Clinical nodes
Negative 77 (75) 26 (25) 1.00 Referent
Positive 221 (49) 232 (51) 2.90 1.74–4.83
Unknown 165 (63) 98 (37) 1.73 1.00–2.99

Grade
Well differentiated 47 (66) 24 (34)
Moderate differentiated 163 (54) 138 (46)
Poorly/undifferentiated 170 (57) 130 (43)
Unknown 83 (56) 64 (44)

Charlson/Dayo score
0 222 (52) 203 (48) 1.00 Referent
1 87 (58) 63 (42) 0.76 0.50–1.15
Z2 30 (71) 12 (29) 0.49 0.23–1.03
Missing 124 (61) 78 (39) 1.22 0.56–2.63

Distance from patient's residence to hospital reporting the case

o50 miles 345 (54) 297 (46) 1.00 Referent
Z50 miles 109 (69) 48 (31) 0.37 0.25–0.55
Unknown 8 (44) 10 (56) 1.61 0.56–4.63
6 M. Mossanen et al. / Urologic Oncology: Seminars and Original Investigations ] (2016) 1–7
Table 2
Continued
Category
Facility type
Community Cancer Program/Comprehensive
Community Cancer Program
Academic/Research program
a
Multivariate model includes only variables that were significantly associated with the outcome in univariate analysis.
chemotherapy. This trend in limited access to care has been
seen for other cancers as well including limited access to
elderly patient with bladder cancer [11]. In this study,
African-American patients were found to have decreased
likelihood of receiving chemotherapy. Evaluation of socio-
economic background in oncologic outcome has demon-
strated that living in deprived areas is associated with
increased mortality for women with invasive breast cancer
[12]. Moreover, patients living greater than 50 miles from a
treatment center were less likely to receive chemotherapy.
Work in women with early stage breast cancer echo these
findings, as a substantial fraction of patients may be willing
to accept suboptimal outcomes because they choose to
forego radiation therapy owing to difficulty in traveling
[13]. Travel time has also been found to effect patient
decisions when contemplating management options for
breast cancer [14]. For urologic malignancies, patients of
lower SES requiring more complex procedures, such as
partial nephrectomy, may face greater need to travel [15].
These findings underscore the need for further investiga-
tions into identifying underserved populations with penile
cancer that may have limited access to care for socio-
economic or geographic reasons.
Multiple challenges face the widespread adoption of
chemotherapy for this patient population. Nodal involvement
with penile cancer is associated with significant mortality
[16]. Once pelvic node involvement occurs, survival is
dismal, and as a result multimodal therapy has emerged
including the use of chemotherapy [17]. Developments in the
optimal regimen for these patients have been sluggish, in part
because of the rare nature of the disease, which limits the
ability to conduct larger studies [18–20]. Early experience
evaluating the efficacy of cisplatin in penile cancer involved
small studies with as little as 2 to 13 patients [21,22]. With
time, larger studies evolved to evaluate less toxic and more
effective regimens in the management of metastatic disease
[2,16]. In the last 10 years, platinum-based chemotherapy
regimens have emerged as promising approaches to facilitate
surgical resection and prolong survival [23]. Institutional
protocols and guidelines statements, including the National
Comprehensive Cancer Network, have also began to emerge
supporting the use of platinum-based chemotherapy regimen
for advanced stage disease [4,24]. For patients with meta-
static disease, taxanes in combination with cisplatinum-based
regimens also have been shown to improve survival [5,25].
No chemotherapy, N (%) Chemotherapy, N (%) Multivariatea odds ratio 95% CI
247 (59) 173 (41)
216 (54) 183 (46)
For elderly patients with poor tolerability, cisplatinum with 5
fluorouracil has also been described as an alternative [26].
Treatment of superficial penile lesions have not changed
dramatically over the time period observed in this study.
The management of these lesions includes laser therapy,
microscopic surgery, glans resurfacing, and partial penec-
tomy [27]. Caring for these lesions is based in part on
provider experience as well as patient preference. Despite
European Association of Urology and National Compre-
hensive Cancer Network guidelines, variability in care
patterns may still persist.
This study is subject to the inherent limitations of any
retrospective study. NCDB data are collected from approx-
imately 1,500 accredited hospitals throughout the United
States and represent approximately 70% of all new cancer
diagnosis [28]. Therefore, this dataset lack generalizability
to less urban areas, as the data are collected from areas with
specialized emphasis in oncology and may also fail to
capture a portion of the population. The NCDB is also
subject to subjective differences in staging at various
institutions. We are also limited by missing data, lack of
central review of pathology, and staging studies. Addition-
ally, the specific chemotherapy drugs received are not
available, nor is cancer-specific mortality data. Despite the
availability of NCCN guidelines, the management of penile
cancer is subject to variability among providers. We also
focused our analysis of localized penile cancer treatment to
partial penectomy and did not include other forms of topical
therapy. Further, this dataset also lacks information regard-
ing specific components of chemotherapy regimens. Lastly,
there is a delay in dissemination of practice patterns and this
natural lag time may hinder the timeliness of the data.
Despite these limitations, we have been able to demon-
strate that the use of partial penectomy in early stage disease
is increasing over the past 2 decades, and that the use of
chemotherapy for metastatic disease is also increasing.
Demographic factors may effect accessibility to appropriate
care for this rare disease. Future multi-institutional, collab-
orative efforts and large-volume datasets may help improve
future understanding of penile cancer.
References
[1] Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA
Cancer J Clin 2013;63:11.
 M. Mossanen et al. / Urologic Oncology: Seminars and Original Investigations ] (2016) 1–7
[2] Sonpavde G, Pagliaro LC, Buonerba C, et al. Penile cancer: current
therapy and future directions. Ann Oncol 2013;24:1179.
[3] Connell CF, Berger NA. Management of advanced squamous cell
carcinoma of the penis. Urol Clin North Am 1994;21:745.
[4] Clark PE, Spiess PE, Agarwal N, et al. Penile cancer: clinical
practice guidelines in oncology. J Natl Compr Canc Netw 2013;11:
594.
[5] Pagliaro LC, Williams DL, Daliani D, et al. Neoadjuvant paclitaxel,
ifosfamide, and cisplatin chemotherapy for metastatic penile cancer: a
phase II study. J Clin Oncol 2010;28:3851.
[6] Hoffman MA, Renshaw AA, Loughlin KR. Squamous cell carcinoma
of the penis and microscopic pathologic margins: how much margin is
needed for local cure? Cancer 1999;85:1565.
[7] Minhas S, Kayes O, Hegarty P, et al. What surgical resection margins
are required to achieve oncological control in men with primary
penile cancer? BJU Int 2005;96:1040.
[8] Li J, Zhu Y, Zhang SL, et al. Organ-sparing surgery for penile cancer:
complications and outcomes. Urology 2011;78:1121.
[9] Opjordsmoen S, Fossa SD. Quality of life in patients treated for penile
cancer. A follow-up study. Br J Urol 1994;74:652.
[10] Maddineni SB, Lau MM, Sangar VK. Identifying the needs of
penile cancer sufferers: a systematic review of the quality of life,
psychosexual and psychosocial literature in penile cancer. BMC Urol
2009;9:8.
[11] Gore JL, Litwin MS, Lai J, et al. Use of radical cystectomy for patients
with invasive bladder cancer. J Natl Cancer Inst 2010;102:802.
[12] Downing A, Prakash K, Gilthorpe MS, et al. Socioeconomic back-
ground in relation to stage at diagnosis, treatment and survival in
women with breast cancer. Br J Cancer 2007;96:836.
[13] Celaya MO, Rees JR, Gibson JJ, et al. Travel distance and season of
diagnosis affect treatment choices for women with early-stage breast
cancer in a predominantly rural population (United States). Cancer
Causes Control 2006;17:851.
[14] Sauerzapf VA, Jones AP, Haynes R, et al. Travel time to radiotherapy
and uptake of breast-conserving surgery for early stage cancer in
Northern England. Health Place 2008;14:424.
7
[15] Mossanen M, Izard J, Wright JL, et al. Identification of underserved
areas for urologic cancer care. Cancer 2014;120:1565.
[16] Hakenberg OW, Protzel C. Chemotherapy in penile cancer. Ther Adv
Urol 2012;4:133.
[17] Culkin DJ, Beer TM. Advanced penile carcinoma. J Urol
2003;170:359.
[18] Protzel C, Hakenberg OW. Chemotherapy in patients with penile
carcinoma. Urol Int 2009;82:1.
[19] Protzel C, Klebingat HJ, Hakenberg OW. Treatment of advanced
penile cancer. Do we need new methods for chemotherapy?. Urologe
A 2008;47:1229.
[20] Protzel C, Ruppin S, Milerski S, et al. The current state of the art of
chemotherapy of penile cancer: results of a nationwide survey of
German clinics. Urologe A 2009;48:1495.
[21] Power DG, Galvin DJ, Cuffe S, et al. Cisplatin and gemcitabine
in the management of metastatic penile cancer. Urol Oncol 2009;
27:187.
[22] Hakenberg OW, Nippgen JB, Froehner M, et al. Cisplatin, metho-
trexate and bleomycin for treating advanced penile carcinoma. BJU
Int 2006;98:1225.
[23] Pettaway CA, Pagliaro L, Theodore C, et al. Treatment of visceral,
unresectable, or bulky/unresectable regional metastases of penile
cancer. Urology 2010;76:S58.
[24] Patil VM, Noronha V, Joshi A, et al. Palliative chemotherapy in
carcinoma penis: does platinum and taxane combination holds a
promise? Urol Ann 2014;6:18.
[25] Pizzocaro G, Nicolai N, Milani A. Taxanes in combination with
cisplatin and fluorouracil for advanced penile cancer: preliminary
results. Eur Urol 2009;55:546.
[26] Shammas FV, Ous S, Fossa SD. Cisplatin and 5-fluorouracil in
advanced cancer of the penis. J Urol 1992;147:630.
[27] Hakenberg OW, Comperat EM, Minhas S, et al. EAU guidelines on
penile cancer: 2014 update. Eur Urol 2015;67:142.
[28] Bilimoria KY, Stewart AK, Winchester DP, et al. The National
Cancer Data Base: a powerful initiative to improve cancer care in the
United States. Ann Surg Oncol 2008;15:683.