Abstract

Despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin, some physicians continue to argue against routine circumcision in a highly emotional and aggressive fashion.[1-5] During 25 years at the University of Michigan Medical Center, we have been impressed by the mortality associated with epidermoid carcinoma of the penis and the relationship of the prepuce to the disease. Herein we attempt to substantiate our clinical impressions and to analyze the views of those opposed to circumcision from an historical and psychosocial viewpoint.

Methods and Materials

The hospital records of 156 patients with the diagnosis of squamous cell carcinoma of the penis were investigated and analyzed as to patient age, status of foreskin, extent of neoplasm, types of therapy and results of treatment. The patients were seen between 1936 and 1968 and were followed for 2 to 29 years. A number of articles decrying the practice of routine neonatal circumcision were carefully examined for possible factors motivating the authors.[1-5]

Results

Patient age. In accordance with findings in most studies, 75 per cent of our patients with squamous cell carcinoma of the penis were 50 years old or more. However, there were 3 men in the third decade of life and 13 in the fourth.

Status of prepuce. No patient had been circumcised prior to the discovery of the penile lesion.

Stage of neoplasm. The carcinoma was confined to the penis in approximately 44 per cent of cases. An additional 24 per cent of patients demonstrated involvement of inguinal lymph nodes by neoplasm that was amenable to resection. In the remaining 32 per cent of patients the lesions were considered inoperable owing to the extent of the local lesion and/or metastases.

Types of therapy. Approximately 70 per cent of the patients underwent surgical procedures, including local excision of the lesion, circumcision, partial penectomy, radical amputation of the penis and lymphadenectomy. Irradiation was used primarily as a palliative measure in patients with extensive inoperable neoplasm. Only 1 patient received chemotherapy.

Results of treatment. At the close of the study, 25 per cent of the patients were alive without evidence of neoplasm. Approximately 75 per cent of the patients were dead: 15 per cent of these patients were free of neoplasm at the time of death, while 37 per cent had evidence of squamous cell carcinoma. No autopsy was performed on the remaining 23 per cent.

Analysis of anti-circumcision publications. The current anti-circumcision crusade can be attributed to a concatenation of factors old and new. From a phylogenic viewpoint the oldest of these factors is man's high valuation of the genitals and the guilt-induced anxiety leading to a fear of genital injury. Since the individual's dread of genital injury or castration is usually resolved by relegation to the unconscious, it may later emerge as a sincere effort to have every penis remain intact. Potentiating this primordial anxiety is a quite understandable backlash against the originally unscientific origins of circumcision and against the lavish claims that were made regarding the benefits accruing to those who underwent the procedure. Like all backlashes, the reaction has been excessive and the anti-circumcision camp now' attempts to demolish fact as well as fancy. The analogy of throwing out the baby with the bath water was never more applicable. However, the catalytic element for the anti-circumcision swell lies in the current aura of protest. Various minority and deprived groups now speak up and demonstrate with unaccustomed vigor. Movements abound to save wild horses, polar bears, islands and lakes. The establishment is seen as a universally bad guy. In this atmosphere the male infant is easily and emotionally envisaged as helpless and unmarred-as indeed he is. The crusade to protect him from carcinoma blends easily into other battles, other conflicts, although the similarity is, of course, a chimera.

Discussion

Careful analysis of our cases of squamous cell carcinoma of the penis reveals that every patient had a foreskin at the time the lesion first appeared. We encountered no patients with carcinoma of the penis who had been circumcised either shortly after birth or thereafter (including adulthood.) Hardner and associates[6] and Riveros and Gorostiaga[7] also found no circumcised patients in their respective series of 100 and 265 cases of penile carcinoma. Our evidence leads us to believe that circumcision at any age will virtually prevent the onset of squamous cell carcinoma of the penis if the neoplasm is not present at the time of circumcision and the prepuce is completely removed. We do not agree with the concept that circumcision after the neonatal period is ineffective in preventing epidermoid neoplasms of the penis. Many adult patients with phimosis, condyloma acuminata and leukoplakia have been circumcised at this medical center and none has reappeared with penile neoplasm. Our data unequivocally refute the concept that carcinoma of the penis is a relatively benign cancer. It is true that the early lesion can be eradicated and the patient given an excellent prognosis. However, a relatively high percentage of patients (more than a third in our series) do not seek medical treatment until the disease is in an incurable state. Thus, carcinoma of the penis becomes a highly lethal neoplasm owing to the act that certain patients do not obtain medical advice early in the course of the disease. Our medical colleagues who argue against routine neonatal circumcision apparently are not cognizant of this fact for they state that penile carcinoma "could probably be prevented by adequate hygiene" and that it "generally has a good prognosis",[1] One must consider not only the effects of the neoplasm upon the patient's life span but the result of the loss of part or all of the penis upon the life style of the patient and his wife. Indeed this aspect may be quite deadly, as is demonstrated by 3 suicides in the Mayo series. The many excellent studies on carcinoma of the penis fully support our findings that some patients do not practice good genital hygiene and are not aware of the potential deadly nature of neglected penile cancer.[7-9] Routine circumcision and the need for conclusive evidence to support the contention that it is medically indicated have been discussed in an editorial.[10] A review of the literature reveals that squamous cell carcinoma of the penis 1) occurs in uncircumcised male subjects, 2) results in the I death of at least a third of patients and 3) can be virtually prevented by adequate circumcision.

Summary

A series of 156 cases of squamous cell carcinoma of the penis is reviewed. The data reveal that no patient was circumcised prior to onset of the neoplasm and that at least a third of the patients died as a result of the disease, Our findings refute the postulations of those opposed to circumcision that penile cancer carries a good prognosis and that prophylactic circumcision is unwarranted. The publications of some of those opposed to circumcision are examined from social and psychodynamic viewpoints.

References

1. Morgan WK. The rape of the phallus. JAMA 1965; 193: 223
2. Morgan WK. Penile plunder. Med J Aust 1967; 1: 1102
3. Letters to the Editor. JAMA 1965; 194: 309.
4. Preston EN. Whither the foreskin? A consideration of routine neonatal circumcision. JAMA 1970; 213: 1003
5. Letters to the Editor JAMA 1970; 214: 2194
6. Hardner GJ, Bhanalaph T, Murphy GP, Albert DJ, Moore RH. Carcinoma of the penis: analysis of therapy in 100 consecutive cases. J Urol 1972; 108: 428
7. Riveros M, Gorostiaga R. Cancer of the penis. Arch Surg 1962; 85: 377
8. Hanash KA, Furlow WL, Utz DC, Harrison EG. Carcinoma of the penis: a clinico. pathologic study. J Urol 1970; 104: 291
9. Ekstrom T, Edsmyr F. Cancer of the penis: a clinical study of 229 cases. Acta Chir Scand 1958; 115: 25
10. Editorial: Routine circumcision. JAMA 1963; 185: 780.

Accepted for publication December 29, 1972. Read at annual meeting of North Central Section, American Urological Association, Chicago, Illinois, September 27-30, 1972.