Patients Experiences Prior to and at the Time of Diagnosis of Penile Cancer

Psychology undoubtedly plays a role in the delay in diagnosis that is commonly seen in this disease as evidenced by the frequency with which patients present with advanced cancer, and the significant delay that commonly occurs between the development of symptoms and the presentation to a physician. For instance, in one series of 700 men, over 50% had at least T2 disease at the time of diagnosis and treatment1 while in a second series of men with a localized tumor of the penis, treated by laser therapy, over a third of patients experienced a delay of more than 6 months between the appearance of symptoms and the definitive diagnosis being made.2 While some of the delays undoubtedly reflect medical misdiagnosis, it has been suggested that between 15% and 50% of men delay seeking treatment for penile cancer for psychological reasons.3 These reasons include fear, embarrassment, and symptom denial despite the abnormality being clearly visible and palpable. While there is a suggestion that this delay is more commonly seen in single men as opposed to married men,2 there is no evidence that it is associated with the age of the patient. Where misdiagno-sis has occurred, the patient will often experience concomitant frustration at the delay in seeing a doctor who is able to recognize and treat the underlying tumor.

The diagnosis itself is typically accompanied by shock, fear, and disbelief.3 The initial concerns usually relate to the diagnosis of cancer and the fear of dying as a result of the disease. At this time, there is typically a dependence upon others which helps many men to cope with the initial shock of the diagnosis. The main support comes from the patient's partner,4 although healthcare professionals and other patients can provide valuable insight into the practicalities of treatment, and perhaps more importantly the relatively good prognosis of patients with penile cancer following treatment.

After the initial shock comes the fear of the practical effects of treatment, which for most patients will involve some form of excisional surgery of the tumor. There is a growing realization for the patient that there may be some impact upon voiding, upon sexual function, and upon masculinity. Although in many patients the stereotypical masculine response to illness is to "get on with it" there will inevitably be underlying concerns and fears. For example there will be anxiety regarding the risk of tumor recurrence and the potential effects upon sexual function and relationships. Within existing relationships, there may be a concern that surgery will significantly affect their sexual life, while men who are not in a relationship will be concerned about starting and maintaining future relationships. Even within close relationships there may be a tendency for the patient to attempt to hide the full extent of the surgery from their partner for fear of ridicule or for fear of sexual incompetence.4 Outside the relationship, it is common for the man to wish to hide the true diagnosis, and to simply be seen as a "cancer sufferer" rather than have to admit to a disease affecting the penis, with the accompanying perception of some reduction in his masculinity. Although any cancer diagnosis results in an inevitable decline in sexuality and a general state of health, this decline is likely to be more significant in men with penile cancer and often does not recover with time.

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