Penile cancer occurs rarely in the United States and Western Europe. In the United States, the incidence is 1 to 2 cases for every 100,000 individuals a year. In Western Europe, it is less than 1% of all male cancers. Risk factors include being uncircumcised, poor hygiene, history of human papillomavirus (HPV) infection, and smoking tobacco. HPV strains 16 and 18, in particular, put men at risk for penile cancer.

The presentation of penile cancer is variable. Patients may present with a penile mass or ulcer. In addition, some patients develop a red, velvety rash or foul-smelling discharge from beneath the foreskin.

Table 1. Stages and Grades of Penile Cancer

Clinicians should have a low threshold to biopsy penile lesions. This can usually be done under local anesthesia. No treatment should be undertaken without a confirmation of an unequivocal permanent section pathology diagnosis. Urologists should not depend on a frozen section diagnosis done at the same time as a partial or total penectomy.

It is important to stage the primary tumor (T), the regional lymph nodes (N), and the presence of distant metastases (M). Several staging systems have been used through the years, but currently, the TNM system is the most widely used.

 The grade of the primary lesion is also considered in determining prognosis (

Magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for the primary lesion.

 MRI is superior to computed tomography (CT) scans in the evaluation of the primary lesion because MRI has excellent soft tissue and spatial resolution. T2-weighted and gadolinium-enhanced T1-weighted images are the most useful in determining the local extent of the penile cancer.

Determining lymph node status also is critical in establishing prognosis. Ravi reported that the 5-year survival rate declined from 95% for patients without nodal disease to 81% for patients with 1 to 3 positive nodes to 50% for patients with 4 or more positive nodes. CT, MRI, and fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) and CT have all been used for the evaluation of inguinal lymph nodes.

 Ultrasound with fine needle aspiration cytology (FNAC) can be useful when there are palpable nodes on physical exam. The European Association of Urology supports the use of FNAC in this circumstance, noting sensitivity of 93%.

CT imaging has been disappointing for the evaluation of inguinal lymph nodes. Horenblas et al reported a series of 14 patients and found that CT had a sensitivity of 36% and a specificity of 100%, but was unable to detect occult metastases in groins without palpable nodes.

 MRI results in evaluation of inguinal nodes have not been superior to CT.

Due to the limitations of standard CT and MRI imaging of the inguinal nodes, FDG PET/CT has gained increasing acceptance as the study of choice for inguinal node imaging. Schlenker et al reported a prospective study of 35 patients with penile cancer and found that the FDG PET/CT had a sensitivity of 88.2% and a specificity of 98.1%, with a positive predictive value of 93.8% and a negative predictive value of 96.3%.

 Graafland et al also utilized FDG PET/CT for penile cancer staging and reported a sensitivity of 91%, a specificity of 100%, and a diagnostic accuracy of 96% in identifying inguinal/pelvic node involvement.

The technique of sentinel node biopsy was introduced by Cabanas in 1977 in an attempt to sample the first landing site of inguinal node metastatic spread.

 His rationale was that this node or cluster of nodes located around the superficial epigastric vein was predictive of the status of the remainder of the inguinal nodes. However, the lymphatic drainage of the penis is variable and several authors have reported false negative rates of 10% to 25%.

 Therefore, this technique, although theoretically attractive, has fallen into disfavor.

To try to improve accuracy, dynamic sentinel lymph node biopsy (DSLNB) was introduced. This technique involves mapping the penile lymphatic drainage with blue dyes and/ or radiotracers.

 The results of DSLNB appear to be highly variable and user dependent; some results were no better than standard lymph node biopsy.

Newer techniques, such as single-photon emission computed tomography (SPECT)/CT have been evaluated in a few centers with encouraging results.

 In a series of 84 patients, plain lymphoscintigraphy identified sentinel lymph nodes in 87% of patients whereas SPECT/CT was able to identify at least 1 node in 100% of patients. However, Jakobsen et al reported a series of 129 patients where the results of SPECT/CT and standard lymphoscintigraphy were essentially equivalent.

 Imaging of the inguinal nodes in penile cancer continues to evolve. However, at the present time, FDG PET/CT is gaining increasing acceptance as the imaging modality of choice.

Carcinoma in situ and verrucous carcinoma of the penis involve the superficial layers of the skin and can usually be treated topically with laser therapy, Mohs surgery, fluorouracil, imiquimod, or cryotherapy.

This article will discuss primary stage II lesions that are best treated by either partial or total penectomy. The goals of therapy should be 2-fold: oncological cure and preservation of sexual function, when possible.

 The primary consideration of surgical planning for the urologist should be to achieve a clear surgical margin. For many years, the traditional dogma had been that a 2-cm margin was required to ensure cure; however, we reviewed our own series and found that all clear surgical margins were equivalent in terms of local control. This has practical implications in the management of the local lesion. A partial penectomy that does not provide enough phallic length for sexual stimulation and/or penetration and that does not afford the patient the ability to stand to void does not benefit the patient. A clear margin that enables sexual pleasure, even without penetration, and maintains the ability for the patient to stand to void is a desirable outcome.

Before either a partial or total penectomy is performed, a permanent pathologic biopsy should always be obtained. Proceeding with definitive extirpative surgery on the basis of a frozen section result represents an unnecessary risk that could result in unindicated disfiguring surgery. However, a frozen section should always be taken at the time of a partial penectomy to confirm a negative margin.

A potential complication of either a partial or total penectomy is stenosis or stricture of the neomeatus. We have published the “rosebud” technique that is based on similar surgical principles utilized in the maturation of an ileal conduit stoma.

The technique involves mobilization of the urethral stump after the completion of either a partial or total penectomy, which should provide a length of urethra of about 1 cm that can then be spatulated (

Figure 1. Urethral Mobilization for Creation of a Neomeatus

Figure 2. Maturation of the Urethral Stump for Creation of a Neomeatus

A total penectomy is preferable in larger or more proximal penile lesions when a partial penectomy would not reliably provide a clear surgical margin. The base of the penis is circumscribed and the corpora cavernosa and corpus spongiosum are dissected proximally. The base of the corpora cavernosa is controlled with mattress sutures, and the urethra is mobilized with attention to preserving its vascularity. A useful technical point is to place an infant feeding tube into the remaining urethral stump and secure it with a suture. The feeding tube can then be grasped with a forceps, which facilitates passage down to the perineum where a neomeatus is created.

The surgical management of the inguinal nodes has evolved. For many years, it was accepted practice to give patients with palpable inguinal nodes a 6-week course of antibiotics to see if the enlarged nodes would resolve before proceeding with a lymphadenectomy. Today, most surgeons proceed with the groin dissection without a course of antibiotics unless the primary lesion is grossly infected.

The management of nonpalpable nodes has also evolved. With more accurate imaging studies, most clinicians proceed with an inguinal dissection if there is radiographic suspicion of metastases. In addition, Tabatabaei has provided useful information regarding the risk of nodal metastases based on the stage and grade of the primary tumor (

The classic open lymphadenectomy is associated with significant morbidity including lower extremity lymphedema, lymphoceles, wound infection, and wound separation. The limits of the dissection are the apex of the femoral triangle distally, the sartorius muscle laterally, the adductor longus medially, and the inguinal ligament superiorally.

Table 2. Positive Node Rate Based on Primary Tumor Stage and Grade

In an attempt to decrease the morbidity of the surgery, Colberg introduced the concept of a modified inguinal lymphadenectomy.

 This technique is used primarily in nonpalpable disease or minimally palpable disease. This technique differs from the standard technique by (1) decreasing the extent of the node dissection by excluding the regions lateral to the femoral artery and caudal to the fossa ovalis, (2) saphenous vein preservation, (3) elimination of transfer of the sartorius muscle, and (4) preservation of the subcutaneous tissue superficial to Scarpa’s fascia. Regardless of whether a standard or modified lymphadenectomy is performed, careful handling of the skin edges is important to avoid postoperative wound complications. We have found the use of the Scott ring retractor useful to achieve this goal.

Modifications of surgical technique continue to be reported. Endoscopic inguinal node dissections (the VEIL procedure) are now being performed with reports of longterm efficacy.

 In addition there is a growing experience with robotic inguinal lymphadenectomy that suggests comparable results to the traditional open dissection.

The potential future advances in the management of penile cancer are exciting. Biomarkers may enable us to diagnose and monitor patients more accurately.

 There are also realistic options to replace the penis with either autologous tissue or with a penile transplant.

The next decade will undoubtedly provide clinicians with new challenges and opportunities for the treatment of patients with penile cancer.

TNM Staging System. Cancer.net website. Penile cancer: stages and grades. cancer.net/cancer-types/penile-cancer/stages-and-grades. Updated August 2017. Accessed May 1, 2018.

Suh Ch, Bahefi AD, Tirumani SH, et al. Multimodality imaging of penile cancer: what radiologists need to know. 

2015;40(2):424-435. doi: 10.1007/ s00261-014-0218-6.

Ravi R. Correlation between the extent of nodal involvement and survival following groin dissection for carcinoma of the penis. 

Hakenberg OW, Compérat EM, Minhas S, et al. EAU guidelines on penile cancer: 2014 update. 

2015;67(1):142-150. doi: 10.1016/j.eururo.2014.10.017.

Horenblas, van Tinteren H, Delamarre JF, et al. Squamous cell carcinoma of the penis: accuracy of tumor, nodes and metastasis classification system, and rate of lymphangiography, computerized tomography scan and fine needle aspiration cytology.

1991;146(5):1279-1283. doi: 10.1016/S0022-5347(17)38068-0.

Heyns CF, Fleshner N, Sanger V, et al. Management of lymph nodes in penile cancer. 

 2010;76(2 suppl 1):S43-57. doi: 10.1016/j.urology.2010.03.001.

Schlenker B, Scher B, Tilling R, et al. Detection of inguinal lymph node involvement in penile squamous cell carcinoma by 18F-fluorodeoxyglucose PET/CT: a prospective single-center study. 

2012;30(1):55-59. doi: 10.1016/j.urolonc.2009.10.012.

Graafland NM, Leijte JA, Valdes Olmas RA, et al. Scanning with 18F-FDG-PET/CT for detection of pelvic nodal involvement in inguinal node-positive carcinoma.

2009;56(2):339-345. doi: 10.1016/j.eururo.2009.05.016.

Cabanas RM. An approach for the treatment of penile carcinoma.

Fossa SD et al. Cancer of the penis. Experience at Norwegian Radium Hospital 1974-1985.

Cabanas RM. Anatomy and biopsy of sentinel lymph nodes. 

Pettaway CA, Pisters LL, Dinney CP, et al. Sentinel lymph node dissection for penile carcinoma: the M.D. Anderson Cancer Center experience. 

 1995;154(6):1999- 2003. doi: 10.1016/S0022-5347(01)66671-0.

Wespes E. The management of regional lymph nodes in patients with penile carcinoma and reliability of sentinel node biopsy.

2007;52(1):15-16. doi: 10.1016/j.eururo.2007.02.045.

Speiss PE, Izawa JI, Bassett R, et al. Preoperative lymphoscintigraphy and dynamic sentinel node biopsy for staging penile cancer: results with pathologic correlation. 

 2007;177(6):2157-2161. doi: 10.1016/j.juro.2007.01.125.

Sadeghi R, Gholami H, Zakavi SR, et al. Accuracy of sentinel lymph node biopsy after inguinal lymph node staging of penile squamous cell carcinoma: systematic review and metaanalysis of the literature.

 2012;187(1):25-31. doi: 10.1016/j.juro.2011.09.058.

Brouwer OR, van den Berg NS, Mathéron HM, et al. A hybrid radioactive and fluorescent tracer for sentinel node biopsy in penile carcinoma as a potential replacement for blue dye. 

 2014;65(3):600-609. doi: 10.1016/j.eururo.2013.11.014.

Jakobsen JK et al. DaPeCa-3: promising results of sentinel node biopsy combined with (18) F-fluorodeoxyglucose positron emission tomography/computed tomography in clinically lymph node-negative patients with penile cancer - a national study from Denmark.

. 2016;118(1):102-111. doi: 10.1111/bju.13243.

Treatment options for penile cancer, by stage. American Cancer Society website. cancer.org/cancer/penile-cancer/treating/by-stage.html. Accessed May 1, 2018.

Loughlin KR. Penile cancer sparing surgery: the balance between oncological cure and functional preservation. 

2018;36(4):153-155. doi: 10.1016/j. urolonc.2017.12.008.

Hoffman MA, Renshaw AA, Loughlin KR. Squamous cell carcinoma of the penis and microscopic pathologic margins: how much margin is needed for local cure?

Loughlin KR. The “rosebud” technique for creation of a neomeatus after partial or total penectomy. 

Tabatabaei S, McDougal WS. Positive node pathology based on primary tumor stage and grade. In: Richie JP, D’Amico AV, eds.

Philadelphia, PA: Elsevier/Sanders; 2005:710-722.

Colberg JW, Andriole GL, Catalona WJ. Long-term follow-up of men undergoing modified inguinal lymphadenectomy for carcinoma of the penis. 

Loughlin KR. Use of Scott ring surgical retractor for inguinal node dissection.

Loughlin KR. Surgical management of penile carcinoma: the inguinal nodes.

 2006;97(5):1125-1134. doi: 10.1111/j.1464-410X.2006.06178.x.

Tobias-Machado M, Tavares A, Molina WR Jr. et al. Video endoscopic inguinal lymphadenectomy (VEIL): minimally invasive resection of inguinal lymph nodes. 

Singh A, Jaipuria J, Goel A. Comparing outcomes of robotic and open inguinal lymph node dissection in patients with cancer of the penis. 

. 2018;199(6):1518- 1525. doi: 10.1016/j.juro.2017.12.061.

Vuichoud C, Klap J, Loughlin KR. The emerging role and promise of biomarkers in penile cancer. 

 2016;43(1):135-143. doi: 10.1016/j. ucl.2015.08.012.

Capelouto CC, Orgill DP, Loughlin KR. Complete phalloplasty with prelaminated osteocutaneous fibula flap. 

 1997;158(6):2238-2239. doi: 10.1016/S0022-5347(01)68213-2.

Bateman C. World’s first successful penis transplant at Tygerberg Hospital. 

 2015;105(4):251-252. doi: 10.7196/SAMJ.9602.

Thoma C. Surgery: first penis transplant in the USA. 

2017;14(8):452. doi: 10.1038/nrurol.2017.88. doi: 10.1038/nrurol.2017.88.

Articles

Kevin R. Loughlin, MD, MBA, discusses the diagnosis, staging, and management of penile cancer.

Surgical Challenges and Opportunities in Treating Penile Cancer

If one had to choose a single word to describe the future of Obamacare, it would probably be “uncertain.” The delays in its implementation, the problems with its website, and the departure of US Secretary of Health and Human Services Kathleen Sibelius all contributed to an inauspicious beginning.

The question that now faces the country is what health care will be like as the Affordable Care Act moves forward. Let’s review some of the issues.

The Supreme Court ruled, in National Federation of Independent Business v HHS, that Obamacare was legal, but was a tax. As such, the Medicaid expansion portion of the law could not be imposed on the states. At present, 27 states, including the District of Columbia, have implemented expansion, 3 are engaged in open debate, and 21 are not moving forward with expansion.

This non-uniform implementation of the law poses several legal conundrums. Rivkin and Casey have opined in the 

 that, if the Medicaid expansion provision is an indirect tax, then the “Uniformity Clause” (Article 1, Section 8, Clause 1) of the Constitution requires that the tax “be uniform throughout the United States.” These legal authors raise the issue that the uneven implementation of the Medicaid expansion of the ACA could be legally interpreted as unequal taxation and, as such, form the basis of future legal challenges to Obamacare. The more recent Hobby Lobby (Burwell v Hobby Lobby) decision by the Court allowed that closely held, for-profit corporations are exempt from the ACA if their owners religiously object to portions of it, and if there are less restrictive means of furthering the law’s interest.

 This ruling opens the way for subsequent challenges to the ACA based on religious beliefs.

Another pending legal issue related to Obamacare is the Halbig case, which challenges the massive tax credits provided to people with financial need who enroll in the program. Again, this challenge relates to the uneven enrollment by the states. These tax credits are only available to citizens in states that have set up the health insurance exchanges under the ACA. The outcome of this challenge remains uncertain.

There have been ongoing reports that not all individuals who enrolled in ACA have paid their premiums. Robert Pear reported that, as of May, about 80% of enrollees had paid their premiums.

 The ultimate size of this shortfall is hard to predict, but the potential impact to insurance companies and physicians is significant.

The unemployment crisis in the United States is a complicated issue. A 

 article, “The Full-Time Scandal of Part-Time America,” by Mortimer Zuckerman,

 presents a cogent case that the ACA mandate that employers provide health insurance to anyone working more than 30 hours per week has fueled at least part of the unemployment crisis by incentivizing employers to lay off full-time employees in favor of part-time workers. The statistics he presents are daunting. In June, full-time jobs decreased by 523,000, while part-time jobs increased by about 800,000. Simultaneously, the number of involuntary part-timers soared to 7.5 million compared with 4.4 million in 2007. Zuckerman cites the Bureau of Labor Statistics as stating that nearly 91 million Americans over the age of 16 years are not working, an all-time high and almost 10 million more than in 2009. The long-range impact of ACA on full-time employment remains a major concern.

With the goal of universal health coverage implicit in the ACA mandates, there will be increasing workforce pressures to provide clinical services. Urologists, whose practices include many elderly patients, are likely to be among those who will most acutely feel the pressure of responding to patient access issues. It is very likely that healthcare extenders such as physician assistants and nurse practitioners will be widely integrated into urological practices. This reality is one of the motivations for the American Urological Association’s initiative to help train more allied professionals, as well as for the organization’s annual census, which will help ascertain the regional concentrations and subspecialty distributions of urologists.

Major provisions of the ACA are still evolving. The implementation of ICD-10 coding has been delayed a year. Its eventual implementation promises to impose an additional burden on urologists in regard to the complexity of day-to-day practice.

It has been estimated that there are 5 times as many codes in ICD-10 than in ICD-9, which translates into training costs for urology office staff and decreased office efficiency.

IPAB, the Independent Payment Advisory Board, which is a component of Obamacare, has not yet been implemented. IPAB would be composed of 15 members appointed by the president and continued by the Senate. These would be full-time positions, so no practicing physicians would be members.

IPAB is charged with cutting Medicare expenditures, but since its members are appointees, rather than elected officials, they would not be answerable to the electorate. It is unknown how such an independent board would handle the sustainable growth rate or the “Doc Fix” that Congress has used several times to temporarily stabilize physician reimbursement under Medicare.

The outcome of the Congressional elections this fall remains uncertain. Many pundits speculate that the Republicans will maintain control of the House and regain control of the Senate. Whatever the outcome, it is extremely unlikely that the ACA will be repealed. However, if the Republicans control both chambers, it is likely they will enact budgetary constraints that will significantly alter Obamacare’s implementation. Whatever the midterm election results are, it seems likely that the disharmony among our elected officials within the Beltway will continue.

The only thing certain about the future of Obamacare is its uncertainty. Although it is unlikely that the ACA will be repealed, the specific provisions of Obamacare are not immutable.

Urologists must stay engaged in the political process; it is the surest way to preserve the best of urologic practice. The proper response for a practicing urologist is to stay informed and to stay involved. The AUA, UROPAC, the American Association of Clinical Urologists and its State Society Network all offer tangible resources to help the clinician stay abreast of, and prepared for, the future. The urologist should not forget that the physician is still trusted by the patient more than any elected official, administrator, or newscaster. The urologist should utilize this unique position to educate his/her patients about the issues involved in healthcare delivery. No one else is better qualified to do it.

			Henry J. Kaiser Family Foundation. Status of state action on the Medicaid expansion decision, 2014. Kaiser Foundation website. http://tinyurl.com/mupys5r. Published June 10, 2014. Accessed July 20, 2014.

			Rivkin DB Jr and Casey LA. The opening for a fresh ObamaCare challenge. WSJ website. http://tinyurl.com/pba6sxq. Published December 5, 2012. Accessed July 25, 2014.

			Wikipedia. Burwell v Hobby Lobby. Wikipedia website. http://en.wikipedia.org/wiki/ Burwell_v._Hobby_Lobby. Accessed July 20, 2014.

			Pear R. Insurers say most who signed up under health law have paid up. NYT website. http://tinyurl.com/n8uazzv . Published May 6, 2014. Accessed July 25, 2014.

			Zuckerman M. The full-time scandal of part-time America. WSJ website. http:// tinyurl.com/lrf4qcy. Published July 14, 2014. Accessed July 25, 2014.

			Hilton L. The switch to ICD-10: are you ready? Urology Times website. http://tinyurl. com/opyny7p. Published August 20, 2013. Accessed July 25, 2014.

If one had to choose a single word to describe the future of Obamacare, it would probably be "uncertain." 

Life After Obamacare

Our country is facing present and future fiscal challenges that have never been encountered before in our nation’s history. Our major entitlement programs are not new. The Social Security bill was passed in 1935 and Medicare was established in 1965. However, in the ensuing decades, the entitlement programs have grown far beyond what anyone could have imagined at the time of their inception. Let’s analyze the current status of the three major entitlement programs—Social Security, Medicare, and Medicaid&mdash;their future growth, and how that will impact the funding of health care.

Fundamental to the financial problems faced by the Social Security Administration is the aging of the baby boomers, which has dramatically altered the worker-to-retiree ratio. 

 summarizes the trend of workers to beneficiaries over the years.

 As can be seen, the number of workers supporting a beneficiary has decreased from 159.4 to 2.9 in the past 70 years. It is projected to decrease even further to 2.1 by 2030.

Similar to Social Security, Medicare costs and enrollment increase as the population ages. The number of people enrolled in Medicare is expected to increase from 47 million in 2010 to 80 million by 2030. Total Medicare spending is projected to increase from $523 billion in 2010 to $932 billion in 2020.

 The Congressional Budget Office (CBO) has written that “future growth in spending per beneficiary for Medicare and Medicaid— the federal government’s major health care programs&mdash;will be the most important determinant of long-term trends in federal spending.”

		Table 1. Ratio of Social Security-Covered Workers to Beneficiaries

President Johnson signed the Medicaid program into law on July 30, 1965. Started as a health coverage program for welfare recipients, it has evolved into a public health insurance program for America’s low-income population, and is also the primary program that provides long-term care to the elderly and people with disabilities.

Total Medicaid outlays in fiscal year 2011 were $432.4 billion, with $275.1 billion, or 64%, representing federal spending and $157.3, or 36%, representing state spending. Medicaid provided healthcare services to an average of 55.7 million people in 2011. About one of every five Americans, or 70.4 million people, were enrolled in Medicaid for at least 1 month in 2011.

 Medicaid enrollment grew by 3.8% between 2010 and 2011.

	The Entitlement Programs and the National Debt

As the entitlement programs have grown over the past decades, they have consumed a larger and larger portion of the federal budget. Simply stated, the federal budget can be divided into mandatory spending and discretionary spending. Discretionary spending is the part of the budget that Congress approves each year. Social Security, Medicare, and Medicaid account for 82% of the mandatory budget program and have no budget limits.

 All three of the major entitlement programs are growing rapidly. It is estimated that, from 2013 to 2023, Social Security expenditures will rise from $809 billion to $1414 billion (+75%), Medicare expenditures will increase from $586 billion to $1,064 billion (+82%), and Medicaid expenditures will rise from $265 billion to $554 billion (+109%). Over the next 3 decades, the number of Americans 65 and above will increase from 13% to 20% of the population.

 This will significantly impact the economic burden of all the entitlement programs. This entitlement expansion will exacerbate the dilemma of our national debt, which now exceeds $17 trillion.

The economic consequences of Obamacare cannot be calculated with certainty at this time. It has been estimated that annual federal spending on Obamacare will reach $250 billion in 2023.

 The unknown long-term effects of Obamacare include the cost of employee insurance on small businesses and the impact of Medicaid expansion on the states.

Many economists consider a 90% debt-to-gross domestic product (GDP) ratio as a benchmark beyond which a national economy’s future growth is jeopardized. The current US debt-to-GDP ratio is 101.6%.

 This dilemma is compounded further as an increasing amount of our debt is owed to foreign sources. From 1970 to 2011, the percentage of our national debt owned by foreigners has increased from 5% to 46%.

 As an increasing amount of our budget is devoted to interest payments, the stability of our national economic underpinning will be compromised further.

The unanswered question is: How strong is our national resolve to confront and solve this gathering storm? Further delays by Congress to make hard choices will only make the inevitable consequences that much more severe.

			Social Security Administration. Frequently Asked Questions: Ratio of Covered Workers to Beneficiaries. Social Security Online. http://tinyurl.com/mylkhbw. Accessed March 25, 2014.

			Wikipedia. Medicare (United States). Wikipedia: The Free Encyclopedia. http:// en.wikipedia.org/wiki/Medicare_(United_States). Accessed March 25, 2014.

			The Henry J. Kaiser Family Foundation. Medicaid: a timeline of key developments. Kaiser Foundation website. http://kff.org/medicaid/timeline/medicaid-a-timeline-ofkey- developments. Accessed March 25, 2014.

			US Department of Health & Human Services. 2012 Actuarial Report On The Financial Outlook For Medicaid. Medicaid website. http://tinyurl.com/ard9vev. Accessed March 28, 2014.

			The Heritage Foundation. Federal spending by the numbers, 2013: government spending trends in graphics, tables and key points. Heritage Foundation website. http://www.heritage.org/research/reports/2013/08/federal-spending-by-thenumbers- 2013. Accessed March 25, 2014.

			Loughlin KR: The gathering storm: Medicare and the unsustainable entitlements. AUANews. 2014;19(1):21-22.

			Trading Economics. United States Government Debt to GDP. Trading Economics website. http://www.tradingeconomics.com/united-states/government-debt-to-gdp. Accessed March 27, 2014.

			Wessel D. Red Ink: Inside the High-Stakes Politics of the Federal Budget. New York: Crown Business; 2012.

Our country is facing present and future fiscal challenges that have never been encountered before in our nation's history. Our major entitlement programs are not new.

Kevin R. Loughlin, MD, MBA

Articles

Surgical Challenges and Opportunities in Treating Penile Cancer

Life After Obamacare

The Burden Of Entitlement Programs on the Future Funding of Health Care