Underutilization of Surgical Standard of Care for Insured Men with Invasive Penile Cancer Editorial Commentary

Introduction: Prior studies of mixed insurance populations have demonstrated poor adherence to surgical standard of care for penile cancer. We used data from the Surveillance, Epidemiology and End Results (SEER) cancer registry linked to Medicare to calculate standard of care adherence to surgical treatment of penile cancer in insured men over the age of 65, focusing on potential social and racial disparities. Methods: This is an observational analysis of patients with T2-4 penile cancer of any histologic subtype without metastasis in the SEER-Medicare database (2004-2015). Standard of care was defined as penectomy (partial or radical) with bilateral inguinal lymph node dissection based on the National Comprehensive Cancer Network guidelines. We calculated proportions of those receiving standard of care and constructed multivariate models to identify factors associated with receiving standard of care. Results: A total of 447 men were included. Of these men 22.1% (99/447) received standard of care while 18.8% (84/447) received no treatment at all. Only 23.3% (104/447) had inguinal lymph node dissection while 80.9% (362/447) underwent total or partial penectomy. Race and socioeconomic status were not associated with decreased standard of care. Increasing age (OR 0.93, 95% CI 0.89-0.96), Charlson Comorbidity Index score >= 2 (OR 0.53, 95% CI 0.29-0.97) and T3 to T4 disease (OR 0.34, 95% CI 0.18-0.65) were associated with not receiving standard of care on adjusted analysis. Conclusions: Rates of standard of care are low among insured men 65 years of age or older with invasive penile cancer, regardless of race or socioeconomic status. This finding is largely driven by low rates of inguinal lymph node dissection. Strategies are needed to overcome barriers to standard of care treatment for men with invasive penile cancer.