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© 2022 The Authors. Société Internationale d'Urologie Journal, published by the Société Internationale d'Urologie, Canada.

Key Words Competing Interests Article Information

Penile cancer, treatment, resources None declared. Soc Int Urol J.2022;3(6):367–369

DOI: 10.48083/SXSE9843

Why Should the Indian Urology and Oncology 
Community Be “Aatmanirbhar” in Penile  
Cancer Research?

Gagan Prakash

Department of Surgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India 

The Hindi word “aatmanirbhar” means self-reliant. It became popular after the “Aatmanirbhar Bharat” policies of the 
current Indian government, and it was named Oxford Hindi Word of the Year 2020[1].

The term should not be confused with being “self-contained” or “isolating away from the world” and it appropri-
ately highlights the need for adopting this philosophy by Indian urological, surgical, and oncological communities 
with respect to penile cancer research.

India has one of the highest incidences of penile cancer, with an age-standardized rate(ASR) of 1.4 and a crude 
rate of 1.3 which is almost the same as the rate for kidney cancer and not far behind that of bladder cancer[2]. In fact, 
penile cancer is the only urological cancer in which the ASR in India exceeds that of world (Figure 1). The European 
Union defines rare cancers as those with an incidence of less than 6 per 100 000 population per year. By this definition, 
prostate, bladder, kidney, and penile cancers would all be considered rare in India. This is in contrast with high and 
high–medium-income countries (HIC, HMIC) where the incidence of penile cancer is much lower than that of other 
urological cancers. A recent editorial from the members of the newly formed Global Society of Rare Genitourinary 
Tumors (GSRGT) pointed out the dichotomy of penile cancer research and incidence: 90% of the publications related 
to rare genitourinary cancers come from HIC and HMIC, despite these countries having the lowest incidence of 
these cancers[3]. Despite having one of the highest incidences of penile cancer, India has hardly any ongoing clinical 
trials. The meagre involvement of low and low–middle-income countries (LMIC) in clinical and translational cancer 
research is well-documented. A recent study reported that only 8% of randomized clinical trials in oncology are from 
LMIC[4]. In other urological cancer sites, the evidence generated in HIC bridges the need for clinical practice in LIC 
and LMIC. For instance, even though > 60% of prostate cancer patients in India present with metastases compared 
with < 4% in the United States, almost all practice-changing evidence that transformed the management of meta-
static prostate cancer in the last decade was generated in the United States, the United Kingdom, and Europe[5]. This 
however may not be possible with rare tumors like penile cancer. India should consider this as both a responsibility 
and an opportunity to lead the way in generating evidence for this not so rare cancer here.

The results of 2 recent surveys representing different parts of the world have clearly highlighted the lack of consensus 
and the variation in patterns of practice in penile cancer management. The first survey was conducted by eUROGEN 
across 10 European countries and found a significant variation in techniques of dynamic sentinel lymph node biopsy 
(DSNB) and templates and boundaries of inguinal lymph node dissection[6]. The more recent survey amongst 1003 
members of the Society of Urologic Oncology (SUO) highlighted a poor utilization of DSNB despite strong evidence 
showing its oncological efficacy and favourable immediate and long-term morbidity[7]. While we expect similar lack 
of consensus amongst Indian centres, the difference is that we have the potential to answer many of these questions for 
ourselves and for the rest of the world. The implication of human papilloma virus (HPV) is being explored in the West 

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in relation to aggressiveness of surgery of primary, selec-
tion of patients for radiotherapy, and prognostication. 
While similar studies have been done on Indian patients 
with head and neck cancers, for penile cancer even basic 
data about incidence and serotyping of HPV are lacking. 
Penile length has a global variation, and an Indian study 
found flaccid and stretched lengths of our men to be 
shorter than those in the western countries[8]. Shorter 
length combined with pre-pubic fat causes buried penis, 
which might translate into more patients requiring a 
total penectomy. Construction and validation of tools to 
gather quality of life information with respect to urinary 
and sexual function and options of penile reconstruction 
need exploration. The European Association of Urology 
risk stratification has been conventionally used since 
2016 when it was first published. Recent studies have 
looked at factors that could better predict micro meta-
static disease in clinically node negative groins, and it is 
encouraging to see 2 such large single-centre series from 
India[9]. Reflecting the findings of the SUO survey, the 
use of inguinal sentinel node biopsy in India is limited. 
The standardization of the more frequently used surgi-
cal procedure, its boundaries, and false negative rates are 
missing in urological guidelines, and India is clearly in a 

position to fill this gap. The perioperative management 
of node positive penile cancer patients has a series of 
unanswered questions related to chemotherapy, radio-
therapy, sequencing, and extent. The InPACT trial is a 
pragmatically designed study which should put to rest 
many of these issues and can make a difference in the 
outcome of many patients globally[10]. Unfortunately, 
the trial has a slow accrual rate and although India sees 
a higher proportion of node positive patients at presen-
tation and can potentially contribute significantly to the 
accrual rate of this trial, not even a single Indian centre 
has been on board for this study so far.

So, how to address this dichotomy of paucity of stud-
ies despite a higher incidence of disease in this part of 
the world? Lack of centralization of health and cancer 
care has been considered by some as a possible impetus. 
Considering the vastness of this country and variability 
in health insurance schemes, empowering decentralized 
cancer care is a more sustainable long-term solution. The 
National Cancer Grid (NCG) envisioned this almost a 
decade ago and has now close to 250 cancer centres on 
board[5]. One of the mandates of NCG is to facilitate 
basic, translational, and clinical research in cancer, and 
collaboration of centres treating penile cancer from 
NCG could be an easy pathway.

India has the advantage of having a spectrum 
of treatment modalities across its centres. Use of 
Tc99m-nanocolloid and or indocyanine green when 
DSNB is performed, and open, laparoscopic, or robotic 
approaches when the groins are addressed invasively, are 
all practiced in the same country. Collaboration across 
centres could convert this variation in treatment prac-
tice into an advantage that may not be possible in many 
other countries.

The ongoing pandemic has made it very clear that 
geographical distance is not an impediment to educa-
tion, and collaborative research should follow the same 
path.

The Urological Society of India and the Association 
of Surgeons of India with its surgical oncology chap-
ter (IASO) and NCG will support future penile cancer 
research that will put India on the map.

FIGURE 1. 

ASR of urological cancers in India versus the world. 

A
ge

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ta

nd
ar

di
ze

d
in

ci
de

nc
e/

10
0 

00
0 

in
di

vi
du

al
s

Prostate Bladder Renal Testicular Penile
0

5

10

15

20

25

30

35
30.7

5.5 5.6

1.6
4.6

1.3 1.8 0.63 0.8 1.6

CANCER
World India

Data source: GLOBOCAN 2020 World Health Organization 
©International Agency for Research on Cancer 2020 
All rights reserved

368 SIUJ  •  Volume 3, Number 6  •  November 2022 SIUJ.ORG

UROLOGY AROUND THE WORLD

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References

1. “Aatmanirbharta” selected as Oxford Hindi word of 2020. Times 
of India. February 4, 2021. Available at: indiatimes.com. Accessed 
September 28, 2022.

2. Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, 
et al. Global cancer statistics 2020: GLOBOCAN estimates of incidence 
and mortality worldwide for 36 cancers in 185 countries. CA Cancer J 
Clin.2021 Feb 4:. doi: 10.3322/caac.21660

3. Bandini M, Ahmed M, Basile G, Watkin N, Master V, Zhu Y et al. A 
global approach to improving penile cancer care. Nat Rev Urol.2021 
Dec 22: 022 Apr;19(4):231-239. doi: 10.1038/s41585-021-00557-y. 
Epub 2021 Dec 22. Erratum in: Nat Rev Urol.2022 Apr;19(4):253. doi: 
10.1038/s41585-022-00569-2.

4. Wells JC, Sharma S, Del Paggio JC, Hopman WM, Gyawali B, Mukherji 
D, et al. An analysis of contemporary oncology randomized clinical 
trials from low/middle-income vs high-income countries. JAMA 
Oncol.2021 Mar1;7(3):379-385. doi:10.1001/jamaoncol.2020.7478

5. Sirohi B, Chalkidou K, Pramesh CS, Anderson BO, Loeher P, El Dewachi 
O, et al. Developing institutions for cancer care in low-income and 
middle-income countries: from cancer units to comprehensive cancer 
centres. Lancet Oncol.2018 Aug;19(8):e395-e406. doi: 10.1016/
S1470-2045(18)30342-5

6. Fankhauser CD, Ayres BE, Issa A, Albersen M, Watkin N, Muneer A, 
et al. Practice patterns among penile cancer surgeons performing 
dynamic sentinel lymph node biopsy and radical inguinal lymph node 
dissection in men with penile cancer: A eUROGEN survey. Eur Urol 
Open Sci.2021 Jan 7;24:39-42. doi: 10.1016/j.euros.2020.12.009. 
PMID: 34337494; PMCID: PMC8317807.

7. Marilin N, Master VA, Pettaway CA, Spiess PE. Current practice 
patterns of society of urologic oncology members in performing 
inguinal lymph node staging/therapy for penile cancer: a survey 
study. Urol Oncol.2021 Jul;39(7):439.e9-439.e15. doi:10.1016/j.
urolonc.2021.03.007. Epub 2021 Mar 26. PMID: 33775532.

8. Promodu K, Shanmughadas K V, Bhat S, Nair KR. Penile length 
and circumference: an Indian study. Int J Impot Res.20 07 
Nov-Dec;19(6):558-63. doi:10.1038/sj.ijir.3901569. Epub 2007 Jun 
14. PMID: 17568760.

9. Sali AP, Prakash G, de Cássio Zequi S, da Costa WH, Murthy V, Soares 
FA, et al. A comparative study of AJCC and the modified staging 
system in pT2/pT3 penile squamous cell carcinoma - a validation on 
an external data set. Histopathology.2022 Feb;80(3):566-574. doi: 
10.1111/his.14575. Epub 2021 Dec 28. PMID:34586682.

10. Canter DJ, Nicholson S, Watkin N, Hall E, Pettaway C; InPACT 
Executive Committee. The International Penile Advanced Cancer 
Trial (InPACT): Rationale and Current Status. Eur Urol Focus.2019 
Sep;5(5):706-709. doi:10.1016/j.euf.2019.05.010. Epub 2019 Jun 1. 
PMID: 31160252.

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