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The Relationship between Circumcision and Cancer of the Penis

E.J. Schoen

For the past 20 years, the controversy surrounding circumcision in the United States has clouded the role of newbom circumcision in preventing penile carcinoma. Undocumented policy statements, heated arguments, media interest, and trendy lay anticircumcision groups have generated much heat and have confused issues that seemed clear prior to 1970.

Documentation in the report of the American Academy of Pediatrics (AAP) Task Force on Circumcision[1] has refocused attention on the evidence favoring the role of newbom circumcision in preventing cancer of the penis. Although the relationship between the uncircumcised state and urinary tract infections in infants was the main factor stimulating the interest of the AAP in newbom circumcision, the Task Force study also revealed data on other aspects of circumcision. Among the most important is a reemphasis on findings first revealed in the early 1930s and never refuted - i.e., that newbom circumcision virtually eliminates penile carcinoma.

In Wolbarst's 1932 review of 1,103 cases of penile cancer in the US[2], none occurred in Jews, even though 33 cases would have been expected since Jews constituted three percent of the population. WoIbarst cited similar figures from Europe and noticed that Moslems who perform circumcision later in childhood also appeared to be protected against penile cancer; protection was not as complete when circumcision was performed in adults. Wolbarst concluded that the earlier in life circumcision was performed, the less the risk of developing penile cancer later, and he urged that all male infants be circumcised to prevent cancer of the penis. He also indicated that non-Jewish patients recognizing the advantages were beginning to have their newbom boys circumcised.

In a classic 1935 report and discussion, Dean[3] analyzed 120 cases of penile cancer from Memorial Hospital in New York City. None were in Jews, although more than one third of other cancer patients at the hospital were Jewish. Like Wolbarst, Dean noted that circumcision Iater in life did not offer the complete protection against penile cancer that newbom circumcision did. In Dean's series, the average age of diagnosis of cancer of the penis was 50, with 22 percent of the cases diagnosed before age 40. Phimosis, paraphimosis, chronic irritation, and syphilis all predisposed to early development of penile cancer. He concluded that 'prophylactic treatment of cancer of the penis consists in circumcising all male infants a few days after birth.' He also expressed frustration that urologists, who are aware of this method of cancer prevention, were not responsible for circumcising newborn boys, and he encouraged obstetricians to perform the procedure.

In the subsequent 56 years, published series from other US medical centers have confirmed Dean's findings. There were reports of 139 penile cancer cases from llinois in 1946[4]; 100 from Roswell Park, New York, in 1972[5]; 156 cases from Michigan in 1973[6]; and 77 from Cleveland in 1986[7]. Of the resulting total 592 penile cancer cases from five institutions around the US, not one of the men had been circumcised in infancy despite the fact that by the mid-1970s most males in the US had been circumcised as newborns[8].

Dagher et al[6], who had reported the series of 156 patients from Michigan in 1973, reflected disappointment in the lack of response of the medical profession to these data, similar to the disappointment expressed by Dean 40 years earlier. 'Despite overwhelming evidence from urological surgeons that neoplasm of the penis is a lethal disease that can be prevented by removal of the foreskin,' they noted, 'some physicians continue to argue against routine circumcision in a highly emotional and aggressive fashion.'

In actuality, the American public and medical profession did respond to this evidence, because preventing cancer of the penis, as well as simplified genital hygiene, was the predominant factor in establishing newborn circumcision as the standard of care in the US in the 1940s. By 1980, it was estimated that more than 50 percent of US males (more than 60 million) had been circumcised[8].

In the past 55 years, there have been 750 to 1,000 penile cancer cases with 200 deaths annually in the US[9-11]; of the total of about 50,000 cases of penile cancer during this period, only 10 of the affected men had been circumcised as newborns[12,13], a ratio of uncircumcised to circumcised men with cancer of 5,000:1. It has been claimed that 'optimal' genital hygiene in uncircumcised males could significantly lower the incidence of penile cancer in the US[14]. This claim is based on the fact that the incidence of penile cancer in underdeveloped countries is between three and six per 100,000, whereas in developed countries with homogenous middle-class populations such as in Scandinavian countries and Japan, the incidence is only one tenth as much[15]. But even with higher hygienic standards, the penile cancer incidence in these smaller, homogenous countries is 1,000 to 3,000 times as great as that in circumcised US males. As noted by Kochen and McCurdy[8], the penile cancer incidence rate cited for the US of one per 100,000 is misleading because it combines circumcised males (who have an incidence rate of essentially zero) and uncircumcised males (who have an incidence rate of 2.2 per 100,000). These authors calculated that if all US men were uncircumcised, there would be more than 3,000 cases of cancer of the penis in the US annually. If all US males received newborn circumcision, however, cancer of the penis would essentially disappear, with only one case expected every two to three years.

The mechanism by which presence of the foreskin predisposes to penile cancer has been debated. Chronic irritation, infectious agents, and chemicals in smegma have all been proposed as etiologic agents. Recently, the human papilloma virus (HPV) has become the prime suspect. In 1947. Plaut and Kohn-Speyer[16] produced condylomata and local squamous cell carcinoma by applying smegma to the skin of mice but were unable to identify an infectious or chemical agent. Since then, HPV, the etiologic agent of condyloma acuminata, has been found in Bowen's disease, a premalignant lesion of the penis, as well as in cancers of the penis and vulva[17]. In 1986, McCance et al[18] isolated HPV Type 16 DNA sequences from 49 percent of 53 carcinomas of the penis found in Brazilian men; an additional nine percent had Type 18 DNA sequences.

Irrespective of the specific etiologic factors in cancer of the penis, its predominance in uncircumcised men is overwhelming. In the US, there are approximately 70 million circumcised and 55 million uncircumcised males. Almost all of the 750 to 1,000 cases of penile cancer reported yearly occur in the 55 million uncircumcised males; only one case occurs about every five years in circumcised males. The uncircumcised cohort is older than the circumcised group because newborn circumcision did not become widespread until the 1940s (by the 1950s, 85 to 90 percent of US male infants, about 1.5 million, were being circumcised annually); in view of Dean's data showing that 22 percent of the cases were less than 40 years old[3], however, hundreds of cases would be expected annually in circumcised males.

Additionally, there are about three million circumcised Jewish males in the US with an age distribution similar to that of uncircumcised males. If Jewish males had the same penile cancer incidence as the uncircumcised cohort (two per 100,000), 60 cases would be expected annually in Jewish men, and yet only five cases of penile cancer have been reported in circumcised US Jewish males in the past 54 years[19], more than 600 times less than expected.

Although cancer of the penis is one of the less common forms of cancer, it is a devastating and lethal disease that affects almost 1,000 US males annually; the three-year mortality rate is 20 to 25 percent, and the usual treatment is penile amputation[7].

Childhood immunizations (for measles, polio, and diptheria-pertussis-tetanus), which have been so important in preventing severe infectious diseases in children, are generally 90 to 95 percent effective; in contract, newborn circumcision is 99.9 percent effective in eliminating cancer of the penis. Expectant parents should be informed of the cancer-preventative aspect of newborn circumcision.

In reviewing educational material in prenatal classes, I have found information on cancer of the penis to be absent or misrepresented. In the field of cancer prevention, routine newborn circumcision is unique in that it is a low-risk prophylactic procedure that offers the promise of virtual elimination of one form of cancer. Recent reviews have indicated that there are a number of health benefits of newborn circumcision that outweigh the low risk of the procedure[20,21]. Prevention of cancer is one of the most important and best documented of these benefits. Prospective parents should be made aware of this fact when they are deciding about newborn circumcision, because universal circumcision has the potential for essentially eliminating this devastating cancer.

References

  1. Schoen EJ, Anderson G, Bohon C, et aI. Report of the American Academy of Pediatrics, Task Force on Circumcision. Pediatrics 1989; 84: 388-391
  2. Wolbarst AL. Circumcision and penile cancer. Lancet 1932; 1: 150-153
  3. Dean AL Jr. Epithelioma of the penis. J Urol 1935; 33: 252-283
  4. Lenowitz H, Graham AP. Carcinoma of the penis. J Urol 1946; 56:458-484
  5. Hardner GJ, Bhanalaph T, Murphy GP, et al. Carcinoma of the penis: Analysis of therapy in 100 consecutive cases. J Urol 1912; 108: 428-430
  6. Dagher R, Selzer ML, Lapides J. Carcinoma of the penis and the anti-circumcision crusade. J Urol 1973; 110: 79-80
  7. Persky L, deKernion J. Carcinoma of the penis. CA 1986; 36: 258-273
  8. Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis: A life-table anaIysis. Am J Dis Child 1980; 134: 484-486
  9. Cutler SJ, Young JL Ir (eds). Third National Cancer Survey: Incidence Data. NCI Monograph 41. DHEW publication No (NIH) 75-787. Bethesda, Md, National Cancer Institute, 1975.
  10. Young JL Jr, Percy CL, Asire AI (eds): Surveillance, Epidemiology, and End Results: Incidence and Mortality Data, 1973-77. NCI Monograph 57. NIH Publication No 81-2330. Bethesda, Md, National Institutes of HeaIth, 1981.
  11. Young JL. Surveillance, Epidemiology and End Results, 1978-82. NCI Monograph. Bethesda, Md, National Institutes of Health, 1986.
  12. Leiter E. Lefkovitis AM: Circumcision and penile carcinoma. NY Stace J Med 1975; 75: 1520-1522
  13. Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol 1987; 138: 861-862
  14. Thompson HC, King LR, Knox E, Korones SB. Report of the ad hoc task force on circumcision. Pediatrics 1975; 56: 610-611
  15. US Department of HeaIth and Human Services. Cancer Incidence in Five Continents (CIV). Washington, DC, National Cancer Institute, USGPO, 1988, pp 750-751.
  16. Plaut A, Kohn-Speyer AC. The carcinogenic action of smegma. Science 1947; 105: 391-392
  17. McCance DJ. Human papillomaviruses and cancer. Biochim Biophys Acta 1986; 823: 195-205
  18. McCance DI, Kalache A, Ashdown K, et al. Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil. Int J Cancer 1986; 37: 55-59
  19. Dean AL Jr. Epithelioma of the penis in a Jew who was circumcised in early infancy. J Urol 1936; 34: 493-499
  20. Wiswell TE: Routine neonatal circumcision: A reappraisal. Am Fam Physician 1990; 41: 859-863
  21. Schoen EJ: The status of circumcision of newboms. N Engl J Med 1990; 322: 1308-1312

Schoen EJ. The relationship between circumcision and cancer of the penis. CA Cancer J Clin 1991; 41: 306-9

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