| Recommendation | Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for penile cancer in men if they have either:
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| Relative value placed on the outcomes considered | Signs and symptoms of penile cancer The GDG considered the positive predictive value to be the most important outcome when identifying which signs and symptoms predict penile cancer. No evidence was found on this outcome. Investigations in primary care for penile cancer The GDG identified sensitivity, specificity, positive predictive values and false negative rates as relevant outcomes to this question. No evidence was found on any of these outcomes. |
| Quality of the evidence | Signs and symptoms of penile cancer No evidence was found pertaining to the positive predictive values of different symptoms of penile cancer in primary care. Investigations in primary care for penile cancer No evidence was found pertaining to the diagnostic accuracy of tests used in primary care patients with suspected penile cancer. |
| Trade-off between clinical benefits and harms | The GDG considered that a potential benefit of recommending which symptoms should prompt a suspected cancer pathway referral would be to identify those men with penile cancer more rapidly. However, the GDG recognised the importance of recommending the “right” symptoms, in order to minimise the number of men without penile cancer who get inappropriately referred whilst maximising the number of men with penile cancer who get appropriately referred. In order to strike an appropriate balance between these considerations, the GDG agreed to recommend referral for those symptoms with a positive predictive value of 3% or above. The GDG were confident that at this threshold the advantages of a suspected cancer pathway referral in those with penile cancer outweighed the disadvantages to those without. However, in this instance, the GDG acknowledged that no evidence had been found on the positive predictive values of symptoms for penile cancer. Despite the lack of evidence, the GDG considered that it was still important to provide guidance on which symptoms should prompt referral for suspected penile cancer. The GDG noted that, based on their clinical experience, penile lesions can be a symptom of penile cancer. However they acknowledged that most penile lesions are caused by sexually transmitted infections rather than cancer. They therefore agreed that a suspected cancer pathway referral should only be recommended after sexually transmitted infections had been excluded as the cause of a penile lesion, in order to reduce inappropriate urological referrals. The GDG also agreed that referral should be considered for those men with other unexplained or persistent symptoms of foreskin and/or glans. The GDG discussed whether an age threshold should be included in the recommendations, as penile cancer is rare in men under 60. However it was noted that the demographics of penile cancer may be changing to include younger men. The GDG therefore agreed not to include an age threshold in the recommendations. Due to the lack of evidence, the GDG were not able to recommend a particular test for the primary care investigation of penile cancer. Equally, the GDG were not able to recommend that no tests be done in primary care. Therefore they agreed not to make any recommendations on this issue. |
| Trade-off between net health benefits and resource use | The GDG noted that no relevant, published economic evaluations had been identified and no additional economic analysis had been undertaken in this area. The GDG considered that the recommendations made were similar to current clinical practice and therefore would not require additional funding. In addition, they noted that penile cancer is very rare and does not affect many men. They therefore agreed the recommendations were likely to be cost-neutral. |
| Other considerations | The GDG noted that the previous guidance had made specific recommendations about men with Peyronie's disease. It was agreed that this group of men would be covered by the recommendation made and did not require specific mention. The GDG considered the situation for transgendered people, who retain any of the genital organs of their genetic sex. The recommendations for cancers generally found in a single sex, also extend to people who have the organs of that sex, whatever their gender. |
From: 12, Urological cancers
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