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Circumcision of baby boys advocated for genital cancer prevention
A review in the September 2012 issue of Asia Pacific Journal of Cancer Prevention argues that any evidence-based programs for prevention of genital cancers in men and women must include the promotion of infant male circumcision. On February 15, 2013, the Federal Health Minister of Australia, Tanya Plibersek, launched a free vaccination program against human papillomavirus (HPV) for all Australian boys. This took place at a high school for performing arts in Sydney. At the launch she asked “If there was something you could do now, as a parent, that would protect your child from a range of cancers and disease in the future when they are adults, wouldn’t you do it?”
Governments should pay heed to the expert evaluation of the issues that was provided in the article. The authors argue that the quadrivalent HPV vaccine will do little to prevent penile cancer, whereas male circumcision will. The review highlights the common misconception that many believe all genital cancers are caused by HPV and that the current HPV vaccines are capable of complete protection against HPV-related disease. In fact only half of penile cancers are associated with HPV. Other risk factors are phimosis, balanitis, and smegma. These increase the risk of penile cancer by 12-, 4-, and 3-fold, respectively. Each of these is more common in, or exclusive to, uncircumcised men.
Since the HPV vaccine is directed at only two of a multitude of oncogenic HPV types, and these two types, HPV16 and HPV18, are responsible for 70% of cervical cancers, if these same two oncogenic HPV types contribute to 70% of penile cancers then, based on the most optimistic of assumptions, the quadrivalent HPV vaccine might reduce penile cancer by 33% (i.e, 70% of half). Since it is unlikely that all boys will be vaccinated, the actual protective effect will be far less. In contrast, male circumcision in infancy is highly protective against penile cancer.
As the recent review article shows, the myth that the HPV vaccine prevents virtually all penile cancers appeared in the New South Wales Cancer Council’s policy statement on male circumcision,, which cited as its source the 2010 infant male circumcision policy of the Royal Australasian College of Physicians. The latter policy was since shown to not be evidence-based. The Cancer Council policy is based on an inadequate understanding of the scientific literature, thus making it an unreliable guide to decision-making. Moreover, penile cancer, while uncommon, is not rare, as it currently affects one in 909 uncircumcised males over their lifetime according to the 2012 policy statement by the American Academy of Pediatrics and a recent extensive review.
Apart from having little impact on penile cancer, other misunderstandings about HPV vaccination persist. While providing some benefit in reducing anal cancer in men who have receptive sexual intercourse with other men, and in reducing the heterosexually transmitted disease of cervical cancer in women, there is unlikely to be any protective effect against prostate cancer.
It is argued that male circumcision needs to be promoted as an effective intervention that is best instituted in the neonatal period because infant circumcision is more highly protective against penile cancer than circumcision later, and provides modest protection against prostate cancer.[3, 8] In women, vaccination of girls should synergize with circumcision of boys early in life in reducing cervical cancer. Either alone is only partially protective.
It should therefore be obvious that the quote from the Health Minister2 should apply unequivocally to infant male circumcision. But male circumcision protects against many other conditions, not just genital cancers, that affect half of uncircumcised males over their lifetime. The protection against infant urinary tract infections that often cause permanent kidney damage is a cogent argument in favour of circumcision in the neonatal period. Circumcision in infancy is more effective than circumcision later for both penile cancer and prostate cancer prevention.
In an alarming new finding, the major HPV vaccine type, HPV16, was identified in the foreskins of 12% of boys aged 5 months to 15 years (mean 5.5 years). The authors pointed out that a reservoir for later HPV-related disease exists in the foreskin of boys even before presumed sexual exposure. This further reinforces arguments favoring circumcision in infancy. It might also suggest that HPV vaccination should occur much earlier than puberty.
Finally, the recent review article provides the first cost-benefit analysis of infant male circumcision in relation to disease prevention, albeit limited to genital cancers. In the USA, an analysis by researchers at Johns Hopkins University that was devoted not just to genital cancers, but infections of the urinary tract in infancy, and viruses, notably HIV, that are transmitted sexually in adulthood, found a considerable cost effectiveness of infant male circumcision. Infant male circumcision was money well spent. Cost of medical treatment would be higher still if the authors had considered all of the other benefits of infant male circumcision. Based on Australian data, the cost to the Australian Government of universal infant male circumcision would be one-tenth that of the initial projected cost of HPV vaccination of girls.
Yes, Minister Plibersek, “If there was something you could do now, as a parent, that would protect your child from a range of cancers and disease in the future when they are adults, wouldn’t you do it?” That “something” is infant male circumcision. But infant male circumcision could be even more beneficial when one considers the wide raft of adverse conditions over the entire lifetime of the boy, and the fact that infant male circumcision has no long-term adverse effects except in very rare cases, and protects his female sexual partners as well. The safety of infant male circumcision is on a par with vaccines. Indeed, the “something you could do now” is to ensure your baby boy gets circumcised.
- Morris BJ, Mindel A, Tobian AAR, et al. Should male circumcision be advocated for genital cancer prevention? Asian Pacific J Cancer Prevent. 2012;13:4839-4842.
- Dunlevy S: Gardasil cervical cancer vaccine to be given to teenage boys in world first. News.com.au. 2013(Feb 15): http://www.news.com.au/lifestyle/health-fitness/gardasil-cervical-cancer-vaccine-to-be-given-to-teenage-boys-in-world-first/story-fneuzlbd-1226578239897.
- Morris BJ, Gray RH, Castellsague X, et al. The strong protection afforded by circumcision against cancer of the penis. (Invited Review). Adv Urol. 2011(Article ID 812368):(21 pages).
- Cancer Council of Australia (2012) Neonatal male circumcision and cancer. http://www.cancer.org.au/news/news-articles/neonatal-male-circumcision-and-cancer.html (last accessed 18 July 2012).
- Royal Australasian College of Physicians Paediatrics and Child Health Division. Circumcision – a guide for parents of infant males. [Brochure]. Accessed 14 Aug 2012.
- Morris BJ, Bailis SA, Castellsague X, et al. RACP's policy statement on infant male circumcision is not evidence based. Aust NZ J Publ Hlth. 2006;30:16-22.
- American Academy of Pediatrics. Circumcision policy statement. Task Force on Circumcision. Pediatrics. 2012;130:e756-e785.
- Wright JL, Lin DW, Stanford JL: Circumcision and the risk of prostate cancer. Cancer. 2012;118:4437-4443.
- Morris BJ, Wodak AD, Mindel A, et al. Infant male circumcision: An evidence-based policy statement. Open J Prevent Med. 2012;2:79-82.
- Morris BJ, Wiswell TE: Circumcision and lifetime risk of urinary tract infections: A systematic review and meta-analysis. J Urol. 2013:Epub ahead of print Nov 27, 2012.
- de Martino M, Haitel A, Wrba F, et al. High-risk human papilloma virus infection of the foreskin in asymptomatic boys. Urology. 2013:Epub ahead of print Jan 18, 2013.
- Morris BJ, Waskett JH, Banerjee J, et al. A ‘snip’ in time: what is the best age to circumcise? BMC Pediatr. 2012;12 (article20):1-15.
- Kacker S, Frick KD, Gaydos CA, et al. Costs and effectiveness of neonatal male circumcision. Arch Pediatr Adolesc Med. 2012;166:910-918.
Brian J. Morris, PhD, DSc, FAHA as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.
School of Medical Sciences, University of Sydney, NSW 2006 Australia