It took a knee injury while running the Dublin City Marathon in 2019 to get Cormac France to his GP about an issue with his penis.
He used the knee as a “cover up”, he says, out of embarrassment when making the appointment over the phone. But once in the consultation room, “I said, ‘now doctor, can I tell you the real reason I’m here, I need to show you something’…”
For many months the father of four had been aware of a “horrible smell” from his nether regions, but had put it down to his tendency after a run to change his sweat-soaked tops as soon as he returned to his home in Leixlip, Co Kildare, but to leave the lower clothes on. He thought this had caused the drying out of skin, but then it got so bad, his penis split, “like lightning hitting the tree”, he says. “I had let it go too far, obviously.”
However, “I had zero pain,” he stresses, so he was not overly worried. In hindsight, he recalls how he was feeling the cold and fatigue for at least a year previously, but it was the knee that was the main problem, after he had taken over an injured friend’s number to run in the marathon.
When his GP, Dr Louise Boyd, examined him, he pressed her for an opinion on what the problem might be. She told him gently that she suspected it was cancer. Such a diagnosis had not entered his head because he had never heard of penile cancer. The very next morning he was called into St James’s Hospital in Dublin, where a urologist referred him to penile cancer specialist Mr Ivor Cullen, a consultant urologist who was working in Waterford University Hospital at the time.
With the cancer having spread to his lymph nodes, “I was almost at the point of no return,” says France, now aged 57 and who works with Eir. He was told if he had put off that GP visit until after Christmas 2019, as he was tempted to do, he probably would not have lived to see the following March.
No part of the body is immune to cancer, but the penile kind is rare. It usually affects men over the age of 50, but can occur in younger men. Treatment may necessitate partial or total amputation and reconstruction.
Over the years in Ireland, various surgeons have treated occasional patients with penile cancer “and the results were probably not very good”, says Cullen. Research has shown that by centralising the care of rare cancers in one place, expertise can be concentrated there, leading to better outcomes for patients.
Three years ago, a national penile cancer centre, led by Cullen, was established in Beaumont Hospital in Dublin, under the HSE’s National Cancer Control Programme (NCCP). It has seen a high success rate in phallus preservation, according to the HSE, “demonstrating the importance of early detection and specialised care for better survival rates and quality of life”.
“When we started,” says Cullen, “they thought that I was going to be doing about 30 or 40 [cases] per year, but in fact, in the last couple of years, we’ve had more than 60 new cases of penile cancer per year” – more than one a week. To put that in context, about 43,000 people in Ireland develop cancer of some kind each year.
Now the NCCP has produced the first patient guide to the condition, Penile Cancer: What I need to know. It offers answers to all those questions most men and their families would be afraid to ask.
“Unlike breast cancer or melanoma or things like that, people are very reluctant to discuss penis cancer; it is a very sensitive subject for men,” says Cullen, who did 18 months of specialist training in London’s University College Hospital, an international centre of expertise in the management of penile cancer. This booklet is really helpful for patients “because it’s quite a stigmatised cancer” and not easy to disclose to friends.
“We must remember as well that penile cancer is, in the large part, a preventable cancer,” he says. One of the main causes are poor penile hygiene with phimosis, ie a tight foreskin, which prevents regular retraction and cleaning of the penis. “That leads to inflammation and it’s this chronic inflammatory process that can become cancerous.”
Circumcision at birth removes the risk of this type of cancer, he explains, “but that does not suggest for a second that I would advocate circumcision for all males”. Rather he would like to see a stronger public health message about the cleaning and proper management of the foreskin, particularly for children and adolescents so they know what good hygiene is for this part of the body going into adulthood.
If a man gets diagnosed with lung cancer, he can nearly go down to the pub and say, ‘look, lads, I have lung cancer,’ whereas this isn’t as open. People don’t want to even mention the word penis, it’s such a taboo
— Penile cancer nurse specialist, Alison Dornan
Another cause of at least half the cases is the human papillomavirus (HPV), which is also linked to cervical, anal, head and neck cancers. In 2019 the HPV vaccination programme for girls in first year of secondary school was extended to boys so, in time, that should have a positive impact on penile cancer rates. But, currently, the Beaumont service is seeing predominantly older men, often from lower socioeconomic backgrounds, who have not been engaged with healthcare services.
“There’s a real stigma about attending your family doctor with a lesion or growth in your penis,” says Cullen. As a result, cases tend to be very advanced by the time help is sought; the cancer has often spread and survival rates are poor. Whereas early forms of penile cancer can be treated with topical creams.
Some years ago patients would often have had their penis amputated, but “nowadays for most patients that will not be necessary. We can get away with removing part of the penis and a lot of times there are reconstructive surgeries that will use skin grafts and skin flaps to maintain as much of the form and function of the penis as possible.”
About two-thirds of new cases being seen at Beaumont are suitable for phallus preservation or reconstructive surgeries, he says, “so that peeing and voiding is satisfactorily maintained, there are no tubes involved, and sexual activity and an intimate life is absolutely possible”.
Alison Dornan, who has been nurse specialist for penile cancer at Beaumont since May 2023, is a vital communication channel for patients and their families, offering both practical and psychological support from the moment they are diagnosed.
“I usually bring them into the family room just to do a debrief, explain any of the terms that they weren’t too sure about, and then I usually give the patients written information as well about the diagnosis.”
As time with a consultant is always limited, pre-surgery she can go through what to expect. Then after surgery she will go up on the ward to review the wounds and, if necessary, educate them and a family member on managing a urinary catheter or drain on discharge. She can organise referrals to psychology services and cancer supports. At Beaumont they are also hoping to set up a peer support group of penile cancer survivors.
“If a man gets diagnosed with lung cancer, he can nearly go down to the pub and say, ‘look, lads, I have lung cancer’, whereas this isn’t as open,” says Dornan. “People don’t want to even mention the word penis, it’s such a taboo.”
Much greater awareness is needed, to break that silence. “Any man who has any issues with their penis or any wound that hasn’t healed within four weeks, they need to get it seen to,” she advises. Instead they have men coming in saying “I’ve had that there for two years, never got it sorted, and now I can’t pee so I’ve come to you.” That’s when we run into problems, she says, recalling one patient in his 30s who could be offered only palliative care after diagnosis.
“It’s just devastating that he left it so long,” says Dornan, who has 183 men on her books. The need for awareness raising extends to health professionals, as GPs will see few if any cases during their careers and the first point of referral is often a dermatologist when it appears to be a skin condition.
Cormac France is very grateful that his GP recognised it as cancer straight away and for the speed and expertise of subsequent treatment. He needed a partial amputation and then all the lymph nodes in his groin area had to be removed. Cullen, he says, did a “brilliant job” in the penile reconstruction and he often reflects on “how lucky I was in my unluckiness, with the people I met”.
Having passed the five-year survival point in recent weeks, how is he now? “I’m certainly a huge amount better than what I was, but I’m not the same person I was. Psychologically [and] physically it has taken a huge toll on me. But I am very thankful to be still here.
“As Mr Cullen said to me, when you’re so fit, it doesn’t stop you getting sick, but it sure helps you in your recovery.”
His marathon running days may be over, at least for now, but his daughter Nicole is running a half-marathon next February in Barcelona, where she lives, to raise awareness of penile cancer over there. It was lack of knowledge about the condition that led her father to delay seeking treatment and he is determined as a survivor to tell as many people as possible about it.
“I don’t want anybody to go through what I went through,” he adds.
Symptoms of penile cancer
- A growth or sore that doesn’t heal within four weeks – it can look like a wart or blister
- Bleeding from your penis or from under the foreskin
- A foul-smelling discharge under the foreskin (not ejaculation)
- Swelling that makes it difficult to draw back the foreskin (phimosis)
- A change in the colour of the skin or foreskin to a bluish / brown colour
- A rash or small crusty bumps on the penis
- Growths on the penis that are bluish-brown
- Lumps under the skin in the groin area
Source: Penile Cancer: What I need to know. Published by the National Cancer Control Programme
