Difference between revisions of "Penile cancer"

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'''Penile cancer''' is a malignant growth found on the [[skin]] or in the tissues of the [[penis]]. Squamous cell carcinoma usually originating in the [[glans penis|glans]] or [[foreskin]] is by far the most common type, occurring in 9 out of 10 cases.<ref>{{REFweb
 +
|quote=
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|url=http://www.cancerhelp.org.uk/help/default.asp?page=22698
 +
|title=Cancer Research UK: Types of penile cancer
 +
|last=
 +
|first=
 +
|publisher=
 +
|website=
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|date=
 +
|accessdate=2008-06-24
 +
}}</ref> Penile cancer is extremely rare, and it tends to develop in men over the age of sixty.<ref>{{REFbook
 +
|last=Frisch
 +
|first=Morten
 +
|init=M
 +
|author-link=Morten Frisch
 +
|url=https://www.academia.edu/35098839/Penile_Cancer
 +
|chapter=Penile Cancer
 +
|title=Cancer Epidemiology and Prevention
 +
|editor=Thun M.J., Linet M.S., Cerhan J.S., Schottenfeld D.
 +
|edition=4
 +
|pages=1029-1038
 +
|publisher={{UNI|Oxford University|Oxon}} Press
 +
|location=New York
 +
|date=2018
 +
|accessdate=2020-09-19
 +
}}</ref>
 +
== Incidence of penile cancer ==
 +
 
 +
In North America the rate of penile cancer has been estimated to be 1 in 100,000<ref>{{REFdocument
 +
|last=Cutler
 +
|init=SJ
 +
|last2=Young Jr
 +
|init2=JL
 +
|title=Third national cancer survey: incidence data
 +
|location=Bethesda, {{USSC|MD}}
 +
|publisher=US Dept of Health, Education, and Welfare, Public Health Service
 +
|date=1975
 +
}}</ref>. Maden et al. (1993) reported penile cancer among a fifth of elderly patients from rural areas who had been [[circumcised]] neonatally and had been born at a time when the rate of neonatal [[circumcision]] was about 20% in rural populations.<ref>{{REFjournal
 +
|last=Maden
 +
|init=C
 +
|last2=Sherman
 +
|init2=KJ
 +
|last3=Beckman
 +
|init3=AM
 +
|last4=Hislop
 +
|init4=TG
 +
|last5=Teh
 +
|init5=CZ
 +
|last6=Ashley
 +
|init6=RL
 +
|etal=yes
 +
|url=http://www.cirp.org/library/disease/cancer/maden/
 +
|title=History of circumcision, medical conditions, and sexual activity and risk of penile cancer
 +
|journal=JNCI
 +
|date=1993
 +
|volume=85
 +
|pages=19-24
 +
|pubmedID=8380060
 +
|pubmedCID=
 +
|DOI=10.1093/jnci/85.1.19
 +
|doi=
 +
|accessdate=2023-09-07
 +
}}</ref> Their study also shows that the rate of penile cancer among men [[circumcised]] neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.
 +
 
 +
Penile cancer is very rare in Europe and North America, occurring in about one in 100,000 men in the latter. It accounts for 0.2% of cancers and 0.1% of deaths from cancer amongst males in the United States. However, in some parts of Africa and South America it accounts for up to 10% of cancers in men.<ref name="What Are the Key Statistics About Penile Cancer?">{{REFweb
 +
|quote=
 +
|url=http://web.archive.org/web/20071030194444/http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea=
 +
|archived=yes
 +
|title=ACS :: What Are the Key Statistics About Penile Cancer?
 +
|last=
 +
|first=
 +
|publisher=
 +
|website=
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|date=2007-10-30
 +
|accessdate=2007-12-13
 +
}}</ref>
 +
 
 +
In Japan, Norway, and Sweden, the risk of penile cancer is about the same  as in the US (1 in 100,000 per year).<ref>{{REFjournal
 +
|last=Wallerstein
 +
|init=E
 +
|title=Circumcision. The uniquely American medical enigma
 +
|journal=Urol Clin North Am
 +
|volume=12
 +
|issue=1
 +
|pages=123-32
 +
|url=http://www.cirp.org/library/general/wallerstein/
 +
|quote=
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|pubmedID=3883617
 +
|pubmedCID=
 +
|DOI=
 +
|date=1985-02
 +
|accessdate=2020-02-10
 +
}}</ref>
 +
 
 +
== Risk factors ==
 +
The major risk factors for penile cancer are advanced age (greater than age 60), use of tobacco, and infection with human papilloma virus.
 +
 
 +
===Circumcision myth===
 +
 
 +
The myth that [[smegma]] was a carcinogenic, and thus that [[circumcision]] would render a man immune to penile cancer, was invented in 1932 by a defender of [[Brit Milah| ritual circumcision]] named [[Abraham L. Wolbarst]], who also believed that [[circumcision]] prevented venereal disease,<ref name="wolbarst1914">{{REFjournal
 +
|last=Wolbarst
 +
|first=Abraham L.
 +
|init=AL
 +
|author-link=Abraham L. Wolbarst
 +
|title=Universal Circumcision as a Sanitary Measure
 +
|journal=JAMA
 +
|date=1914-1-10
 +
|volume=62
 +
|issue=2
 +
|pages=92-97
 +
|url=https://jamanetwork.com/journals/jama/article-abstract/453164
 +
|pubmedID=
 +
|pubmedCID=
 +
|DOI=
 +
|doi=10.1001/jama.1914.02560270008003
 +
|accessdate=2023-09-06
 +
}}</ref> epilepsy, paralysis, and [[masturbation]].<ref>{{Wolbarst1932}}</ref> No laboratory or clinical research had been done on the subject at the time, however Wolbarst's myth found its way into early medical textbooks regardless. Although the smegma hypothesis was completely disproven by an exhaustive study by Reddy in 1963,<ref name="reddy1963">{{REFjournal
 +
|init=DG
 +
|last=Reddy
 +
|init2=IK
 +
|last2=Baruah
 +
|title=Carcinogenic Action of Human Smegma
 +
|journal=Archives of Pathology
 +
|volume=75
 +
|issue=4
 +
|date=1963-04
 +
|pages=414-420
 +
|pubmedID=13973496
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
|accessdate=2023-09-06
 +
}}</ref> circumcision advocates continue to stubbornly repeat it.
 +
 
 +
The American Cancer Society (1996) pointed out that incidence of penile cancer is lower in nations that do not circumcise and urged the [[American Academy of Pediatrics]] ''not'' to promote child [[circumcision]] as a preventive against cancer.<ref>{{REFweb
 +
|url=https://www.nocirc.org/position/acs.php
 +
|title=Letter to American Academy of Pediatrics
 +
|last=
 +
|first=
 +
|init=
 +
|publisher=American Cancer Society
 +
|date=1996-02-16
 +
|accessdate=2023-09-06
 +
}}</ref>
 +
 
 +
===Infection with human papilloma virus===
 +
 
 +
The link between the presence of [[human papillovirus]] (HPV) and genital cancer was established in the 1980s.<ref>{{REFjournal
 +
|last=zur Hausen
 +
|init=H
 +
|title=Genital papillomavirus infections
 +
|journal=Prog Med Virol
 +
|date=1985
 +
|volume=32
 +
|pages=15-21
 +
|pubmedID=2991988
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
|accessdate=2023-09-07
 +
}}</ref><ref>{{REFjournal
 +
|last=Kaufman
 +
|init=RH
 +
|last2=Adam
 +
|init2=E
 +
|title=[[Herpes]] simplex virus and human papilloma virus in the development of cervical carcinoma
 +
|journal=Clin Obstet Gynecol
 +
|date=1986
 +
|volume=3
 +
|pages=678-692
 +
|pubmedID=3019599
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
|accessdate=2023-09-07
 +
}}</ref><ref>{{REFjournal
 +
|last=McCance
 +
|init=DJ
 +
|last2=Kalache
 +
|init2=A
 +
|last3=Ashdown
 +
|init3=K
 +
|etal=yes
 +
|url=http://www.cirp.org/library/disease/cancer/mccance/
 +
|title=Human papillomavirus types 16 and 18 in carcinomas of the penis from Brazil
 +
|journal=Int J Cancer
 +
|date=1986
 +
|volume=37
 +
|pages=55-59
 +
|pubmedID=3000954
 +
|pubmedCID=
 +
|DOI=10.1002/ijc.2910370110
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref><ref>{{REFjournal
 +
|last=Villa
 +
|init=LL
 +
|last2=Lopes
 +
|init2=A
 +
|title=Human papillomavirus DNA sequences in penile carcinomas in Brazil
 +
|journal=Int J Cancer
 +
|date=1986
 +
|volume=37
 +
|issue=6
 +
|pages=853-5
 +
|pubmedID=3000954
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref><ref>{{REFjournal
 +
|last=McCance
 +
|init=DJ
 +
|title=Human papillomaviruses and cancer
 +
|journal=Biochem Biophys Acta
 +
|date=1986
 +
|issue=823
 +
|pages=195-206
 +
|pubmedID=3011085
 +
|pubmedCID=
 +
|DOI=10.1016/0304-419x(86)90002-8
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref><ref>{{REFjournal
 +
|last=Barrasso
 +
|init=R
 +
|last2=De Brux
 +
|init2=J
 +
|last3=Croissant
 +
|init3=O
 +
|etal=yes
 +
|title=High prevalence of papillomavirus-associated penile intraepithelial neoplasia in sexual partners of women with cervical intraepithelial neoplasia
 +
|journal=N Engl J Med
 +
|date=1987-10-08
 +
|volume=317
 +
|issue=15
 +
|pages=916-23
 +
|pubmedID=3041217
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref> [[Ronald L. Poland| Poland]] identified human papilloma virus (HPV) types 16 and 18 as the cause of penile and cervical cancers in 1990, and that they could be spread by sexual contact.<ref name="poland1990">{{REFjournal
 +
|last=Poland
 +
|init=RL
 +
|author-link=Ronald L. Poland
 +
|url=http://www.cirp.org/library/general/poland/
 +
|title=The question of routine neonatal circumcision
 +
|journal=N Eng J Med
 +
|date=1990
 +
|volume=322
 +
|pages=1312-5
 +
|pubmedID=2183058
 +
|pubmedCID=
 +
|DOI=10.1056/NEJM199005033221811
 +
|accessdate=2023-09-07
 +
}}</ref> At least one study suggests that [[circumcised]] men are at higher risk for HPV infection,<ref name="cook1993">{{REFjournal
 +
|last=Cook
 +
|init=LS
 +
|last2=Koutsky
 +
|init2=LA
 +
|last3=Holmes
 +
|init3=KK
 +
|url=http://www.cirp.org/library/disease/STD/cook2/
 +
|title=Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic
 +
|journal=Genitourin Med
 +
|date=1993
 +
|volume=69
 +
|pages=262-4
 +
|pubmedID=7721284
 +
|pubmedCID=1195083
 +
|DOI=10.1136/sti.69.4.262
 +
|doi=
 +
|accessdate=2023-09-07
 +
}}</ref> making being [[circumcised]] a risk factor.
 +
 
 +
===Use of tobacco===
 +
 
 +
Hellberg et al. (1986) identified tobacco use as another risk factor for cancer of the penis.<ref>{{REFjournal
 +
|last=Hellberg
 +
|init=D
 +
|last2=Valentin
 +
|init2=J
 +
|last3=Eklund
 +
|init3=T
 +
|last4=Nilsson
 +
|first4=Staffan
 +
|init4=S
 +
|url=http://www.cirp.org/library/disease/cancer/hellberg1/
 +
|title=Penile cancer: is there an epidemiological role for smoking and sexual behavior?
 +
|journal=Brit Med J
 +
|date=1987
 +
|volume=295
 +
|issue=6609
 +
|pages=1306-8
 +
|pubmedID=3120988
 +
|pubmedCID=1248379
 +
|DOI=10.1136/bmj.295.6609.1306
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref> The use of tobacco has since been a well established risk factor in cancer of the penis.<ref>{{REFjournal
 +
|last=Harish
 +
|init=K
 +
|last2=Ravi
 +
|init2=R
 +
|url=http://www.cirp.org/library/disease/cancer/harish/
 +
|title=The role of tobacco in penile carcinoma
 +
|journal=Brit J Urol
 +
|date=1995
 +
|volume=75
 +
|issue=3
 +
|pages=375-377
 +
|pubmedID=7735804
 +
|pubmedCID=
 +
|DOI=10.1111/j.1464-410x.1995.tb07352.x
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref><ref>{{REFjournal
 +
|last=Rogus
 +
|init=BJ
 +
|title=Squamous cell carcinoma in a young circumcised man
 +
|journal=J Urol
 +
|date=1987
 +
|volume=138
 +
|issue=4
 +
|pages=861-2
 +
|pubmedID=3656549
 +
|pubmedCID=
 +
|DOI=10.1016/s0022-5347(17)43402-1
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref><ref>{{REFjournal
 +
|last=Maden
 +
|init=C
 +
|etal=yes
 +
|title=History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer
 +
|journal=Journal of the National Cancer Institute
 +
|volume=85
 +
|issue=1
 +
|date=1993-01-06
 +
|pages=19-24
 +
|pubmedID=8380060
 +
|pubmedCID=
 +
|DOI=10.1093/jnci/85.1.19
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref>
 +
 
 +
Other risks include poor hygiene, and an increased number of sexual partners (30 partners or more).<ref>{{REFjournal
 +
|last=Brinton
 +
|init=LA
 +
|last2=Reeves
 +
|init2=WC
 +
|last3=Brenes
 +
|init3=MM
 +
|etal=yes
 +
|title=The male factor in the etiology of cervical cancer among sexually monogamous women
 +
|journal=Int J Cancer
 +
|date=1989
 +
|volume=44
 +
|issue=2
 +
|pages=199-203
 +
|pubmedID=2547727
 +
|pubmedCID=
 +
|DOI=10.1002/ijc.2910440202
 +
|doi=
 +
|accessdate=2023-09-08
 +
}}</ref>
 +
 
 +
===Circumcision as a risk factor===
  
−
'''Penile cancer''' is a malignant growth found on the skin or in the tissues of the [[penis]]. Squamous cell carcinoma usually originating in the [[glans penis|glans]] or [[foreskin]] is by far the most common type, occurring in 9 out of 10 cases.<ref>{{REFweb
+
Bissada et al. (1986) reported cancer forms on the [[circumcision scar]].<ref name="bissada1986">{{REFjournal
−
  | quote=
+
|last=Bissada
−
  | url=http://www.cancerhelp.org.uk/help/default.asp?page=22698
+
|init=NK
−
  | title=Cancer Research UK: Types of penile cancer
+
|author-link=
−
  | last=
+
|last2=Morcos
−
  | first=
+
|init2=RR
−
  | publisher=
+
|author2-link=
−
  | work=
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|last3=el-Senoussi
−
  | date=
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|init3=M
−
  | accessdate=2008-06-24
+
|author3-link=
−
}}</ref> Penile cancer is extremely rare, and it tends to develop in men over the age of sixty.
+
|etal=no
 +
|title=Post-circumcision carcinoma of the penis. I. Clinical aspects
 +
|journal=J Urol
 +
|location=
 +
|date=1986-02
 +
|volume=135
 +
|issue=2
 +
|pages=283-5
 +
|url=http://www.cirp.org/library/disease/cancer/bissada1/
 +
|quote=
 +
|pubmedID=3944860
 +
|pubmedCID=
 +
|DOI=10.1016/s0022-5347(17)45614-x
 +
|accessdate=2020-02-10
 +
}}</ref> The [[circumcision scar]] may provide an entry point for HIV. [[Circumcision]] should now be considered a risk factor for penile cancer.
 +
 
 +
===Other risks===
 +
[[Phimosis]] has been implicated as a risk factor in sexually active males, because a non-retractile [[foreskin]] may result in poor hygiene, and because men with [[phimosis]] are at higher risk for lichen sclerosus (also known as [[balanitis xerotica obliterans]]), which may also be a risk factor.<ref name="Rickwood">{{REFjournal
 +
  |url=http://web.archive.org/web/20080513042221/http://bmj.bmjjournals.com/cgi/eletters/321/7264/792
 +
  |REM=http://web.archive.org/web/20080513042221/http://bmj.bmjjournals.com/cgi/eletters/321/7264/792#110919
 +
|archived=yes
 +
  |title=Rapid Responses for Rickwood et al.
 +
  |last=Various authors
 +
  |first=
 +
  |journal=BMJ
 +
  |volume=321
 +
  |issue=7264
 +
|pages=792-3
 +
|pubmedID=
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
  |accessdate=2022-03-13
 +
}}</ref> Adult males with a non-retractable [[foreskin]] who are sexually active may want to have the phimotic condition corrected. (For conservative treatment options, see [[phimosis]].)
  
 
== Symptoms ==
 
== Symptoms ==
  
 
Symptoms include redness, irritation, a sore or a lump on the penis.<ref>{{REFweb
 
Symptoms include redness, irritation, a sore or a lump on the penis.<ref>{{REFweb
−
  | quote=
+
  |quote=
−
  | url=http://www.medicinenet.com/penis_cancer/page2.htm
+
  |url=http://www.medicinenet.com/penis_cancer/page2.htm
−
  | title=Penis Cancer
+
  |title=Penis Cancer
−
  | last=
+
  |last=
−
  | first=
+
  |first=
−
  | publisher=
+
  |publisher=
−
  | work=
+
  |website=
−
  | date=
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  |date=
−
  | accessdate=2008-06-24
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  |accessdate=2008-06-24
 
}}</ref>
 
}}</ref>
  
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== Staging ==
 
== Staging ==
−
 
+
Like many malignancies, penile cancer can spread to other parts of the body. It is usually a primary malignancy, the initial place from which a cancer spreads in the body. Much less often it is a secondary malignancy, one in which the cancer has spread to the penis from elsewhere. Doctors use the extent of [[metastasis]] to estimate what stage the disease is in, to aid in treatment decisions and prognosis. The stages are assessed as follows (Jackson's staging):
−
Like many malignancies, penile cancer can spread to other parts of the body. It is usually a primary malignancy, the initial place from which a cancer spreads in the body. Much less often it is a secondary malignancy, one in which the cancer has spread to the penis from elsewhere. Doctors use the extent of [[metastasis]] to estimate what stage the disease is in, to aid in treatment decisions and prognosis. The stages are assessed as follows(Jackson's staging):
 
  
 
* Stage I - Cancer has only affected the [[glans penis|glans]] and/or foreskin.
 
* Stage I - Cancer has only affected the [[glans penis|glans]] and/or foreskin.
 
* Stage II - Cancer has spread to the [[penis|shaft]] of the penis.
 
* Stage II - Cancer has spread to the [[penis|shaft]] of the penis.
−
* Stage III - Mobile (operable) inguinal lymph nodes
+
* Stage III - Mobile (operable) inguinal lymph nodes.
 
* Stage IV - Fixed (inoperable) inguinal lymph nodes or distant metastasis.
 
* Stage IV - Fixed (inoperable) inguinal lymph nodes or distant metastasis.
  
 
* Recurrent - Cancer that has returned after treatment.
 
* Recurrent - Cancer that has returned after treatment.
  
−
Prognosis can range considerably for patients, depending where on the scale they have been staged. Generally speaking, the earlier the cancer is diagnosed, the better the prognosis. The overall 5-year survival rate for all stages of penile cancer is about 50%.
+
Prognosis can range considerably for patients, depending where on the scale they have been staged. Generally speaking, the earlier the cancer is diagnosed, the better the prognosis. The overall 5-year survival rate for all stages of penile cancer is about 50 percent.
  
 
== Treatment ==
 
== Treatment ==
  
 
There are several treatment options for penile cancer, depending on staging. They include surgery, radiation therapy, chemotherapy, and biological therapy. The most common treatment is one of five types of surgery:
 
There are several treatment options for penile cancer, depending on staging. They include surgery, radiation therapy, chemotherapy, and biological therapy. The most common treatment is one of five types of surgery:
−
* Wide local excision - The tumor and some surrounding healthy tissue are removed
+
 
−
* Microsurgery - Surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible
+
* Wide local [[excision]] - The tumor and some surrounding healthy tissue are removed.
−
* Laser surgery - laser light is used to burn or cut away cancerous cells
+
* Microsurgery - Surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible.
−
* [[Circumcision]] - cancerous foreskin is removed
+
* Laser surgery - laser light is used to burn or cut away cancerous cells.
−
* Amputation ([[penectomy]]) - a partial or total removal of the penis, and possibly the associated lymph nodes.   
+
* [[Circumcision]] - cancerous foreskin is removed.
 +
* [[Amputation]] ([[penectomy]]) - a partial or total removal of the penis, and possibly the associated lymph nodes.   
  
 
Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence. With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy.
 
Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence. With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy.
 
In addition to all the above, treatment of the underlying disease like Brucellosis, is important to limit disease recurrence.
 
In addition to all the above, treatment of the underlying disease like Brucellosis, is important to limit disease recurrence.
  
−
== Risk factors ==
+
== Circumcision as prevention myth==
  
−
The exact cause of penile cancer is unknown.
+
The myth that [[circumcision]] rendered males immune to penile cancer was invented in 1932 by a New York doctor named [[Abraham L. Wolbarst]], {{MD}}<ref name="Wolbarst 1932">{{Wolbarst1932}}</ref> Wolbarst wrote an article that was published in ''The Lancet'' in 1932, implicating human male [[smegma]] as carcinogenic.<ref name="Wolbarst 1932"/> His hypothesis had absolutely no basis in valid scientific and epidemiological research.<ref name="FleissPM HodgesFM 1996">{{REFjournal
 +
|last=Fleiss
 +
|init=PM
 +
|author-link=Paul M. Fleiss
 +
|last2=Hodges
 +
|init2=F
 +
|author2-link=Frederick M. Hodges
 +
|url=http://www.cirp.org/library/disease/cancer/fleiss/
 +
|title=Neonatal circumcision does not protect against cancer
 +
|journal=BMJ
 +
|date=1996
 +
|volume=312
 +
|issue=7033
 +
|pages=779-80
 +
}}</ref> Wolbarst was directly responsible for proliferation of this myth, and all subsequent repetitons of it can be traced to his opinion article, although Wolbarst himself advocated universal neonatal circumcision principally as a preventive for epilepsy, paralysis, and [[masturbation]].<ref name="FleissPM HodgesFM 1996"/>
  
−
The myth that [[smegma]] was a carcinogenic, and thus that [[circumcision]] would render a man immune to penile cancer, was invented in 1932 by a man named Abraham L. Wolbarst, who also believed that circumcision prevented epilepsy, paralysis, and masturbation.<ref>Wolbarst A. Circumcision and Penile Cancer. The Lancet, vol. 1 no. 5655 (January 16, 1932): pp. 150-153.</ref> No laboratory or clinical research had been done on the subject at the time, however Wolbarst's myth found its way into early medical textbooks regardless. Although the smegma hypothesis was completely disproven by an exhaustive study by Reddy in 1963,<ref>D.G. Reddy; I.K. Baruah. "Carcinogenic Action of Human Smegma," Archives of Pathology, vol. 75, no. 4 (April 1963): pp. 414-420.</ref> circumcision advocates continue to stubbornly repeat it.
+
Wolbarst's opinion piece led to the perpetuation of the myth that penile cancer could not happen to males that were circumcised in infancy. This myth was completely disproven when Boczko et al. (1979) reported the 9th documented case of penile cancer in a man who had been [[circumcised]] in infancy from the time of Wolbarst's opinion piece to the time of the report in 1968 (though they would maintain that "performing [circumcision] in infancy continues to be the most effective prophylactic measure against penile carcinoma").<ref name="boczko1979">{{REFjournal
 +
|last=Boczko
 +
|init=S
 +
|last2=Freed
 +
|init2=S
 +
|url=http://www.cirp.org/library/disease/cancer/boczko/
 +
|title=Penile carcinoma in circumcised males]
 +
|journal=N Y State J Med
 +
|date=1979
 +
|volume=79
 +
|issue=12
 +
|pages=1903-4
 +
}}</ref> Boczko et al. (1979) wrote: ''"The diagnosis in our patient was made late, as in the other cases reported, perhaps because the disease was presumed not to occur in those [[circumcised]] in infancy. This is clearly not so. Although rare, the diagnosis must be considered when evaluating a penile lesion even in a circumcised individual."''
  
−
The link between the presence of [[human papillovirus]] (HPV) and genital cancer was established in the 1980s.<ref>zur Hausen H. Genital papillomavirus infections. Prog Med Virol 1985;32:15-21.</ref><ref>Kaufman RH, Adam E: Herpes simplex virus and human papilloma virus in the development of cervical carcinoma. Clin Obstet Gynecol 1986; 3: 678-692</ref><ref>McCance DJ, 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</ref><ref>Villa LL, Lopes A. Human papillomavirus DNA sequences in penile carcinomas in Brazil. Int J Cancer 1986;37(6):853-5.</ref><ref>McCance DJ. Human papillomaviruses and cancer. Biochem Biophys Acta 1986;823:195-206</ref><ref>Barrasso R, De Brux J, Croissant O, et al. High prevalence of papillomavirus-associated penile intraepithelial neoplasia in sexual partners of women with cervical intraepithelial neoplasia. N Engl J Med 1987 Oct 8;317(15):916-23.</ref> Poland identified human papilloma virus (HPV) types 16 and 18 as the cause of penile and cervical cancers in 1990, and that they could be spread by sexual contact.<ref>Poland RL. The question of routine neonatal circumcision. N Eng J Med 1990; 322:1312-5.</ref> At least one study suggests that circumcised men are at higher risk for HPV infection,<ref>Cook LS, Koutsky LA, Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993;69:262-4</ref> making being circumcised a risk factor.
+
In 1993, Christopher Maden, {{PhD}}, et al. reported a study in which 110 men with penile cancer, diagnosed from January 1979, to July, 1990, were interviewed. Of these 110 men, 22 had been [[circumcised]] at birth, 19 later in life, and 69 never.<ref>{{REFjournal
 +
|last=Poland
 +
|init=R
 +
|title=The question of routine neonatal circumcision
 +
|journal=New Engl J Med
 +
|url=https://www.cirp.org/library/general/poland/
 +
|date=1990
 +
|volume=322
 +
|issue=18
 +
|pages=1312-4
 +
|pubmedID=2183058
 +
|pubmedCID=
 +
|DOI=10.1056/NEJM199005033221811
 +
|doi=
 +
|accessdate=2023-09-06
 +
}}
 +
}}</ref> As cases of penile cancer in circumcised men begin to accumulate<ref>{{REFjournal
 +
|last=Pec Jr
 +
|init=J
 +
|last2=Pec Sr
 +
|init2=J
 +
|last3=Plank
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|init3=L
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|last4=Plank
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|init4=J
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|last5=Lazarova
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|init5=Z
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|last6=Kliment
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|init6=J
 +
|title=Squamous cell carcinoma of the penis. Analysis of 24 cases
 +
|journal=Int Urol Nephrol
 +
|date=1992
 +
|volume=24
 +
|pages=193-200
 +
}}</ref><ref name="Aynaud etal 1994">{{REFjournal
 +
|last=Aynaud
 +
|init=O
 +
|last2=Ionesco
 +
|init2=M
 +
|last3=Barrasso
 +
|init3=R
 +
|title=Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings
 +
|journal=Cancer
 +
|date=1994
 +
|volume=74
 +
|pages=1762-7
 +
}}</ref><ref>{{REFjournal
 +
|last=Bissada
 +
|init=NK
 +
|last2=Morcos
 +
|init2=RR
 +
|last3=el-Senoussi
 +
|init3=M
 +
|url=http://www.cirp.org/library/disease/cancer/bissada1/
 +
|title=Post-circumcision carcinoma of the penis. I. Clinical aspects
 +
|journal=J Urol
 +
|date=1986
 +
|volume=135
 +
|pages=283-5
 +
}}</ref><ref>{{REFjournal
 +
|last=Rogus
 +
|init=BJ
 +
|title=Squamous cell carcinoma in a young circumcised man
 +
|journal=J Urol
 +
|date=1987
 +
|volume=138
 +
|pages=861-2
 +
}}</ref><ref>{{REFjournal
 +
|last=Windahl
 +
|init=T
 +
|last2=Hellsten
 +
|init2=S
 +
|title=Laser treatment of localized squamous cell carcinoma of the penis
 +
|journal=J Urol
 +
|date=1995
 +
|volume=154
 +
|pages=1020-3
 +
}}</ref><ref>{{REFjournal
 +
|last=Leiter
 +
|init=E
 +
|last2=Lefkovitis
 +
|init2=AM
 +
|title=Circumcision and penile carcinoma
 +
|journal=N Y State J Med
 +
|date=1975
 +
|volume=75
 +
|pages=1520-2
 +
}}</ref><ref>{{REFjournal
 +
|last=Onuigbo
 +
|init=WI
 +
|title=Carcinoma of skin of penis
 +
|journal=Br J Urol
 +
|date=1985
 +
|volume=57
 +
|pages=465-6
 +
}}</ref><ref>{{REFjournal
 +
|last=Korczak
 +
|init=D
 +
|last2=Siegel
 +
|init2=Y
 +
|last3=Lindner
 +
|init3=A
 +
|title=[Verrucous carcinoma of the penis]
 +
|journal=Harefuah
 +
|date=1989
 +
|volume=117
 +
|pages=436-7
 +
}}</ref><ref>{{REFjournal
 +
|last=Girgis
 +
|init=AS
 +
|last2=Bergman
 +
|init2=H
 +
|last3=Rosenthal
 +
|init3=H
 +
|last4=Solomon
 +
|init4=L
 +
|title=Unusual penile malignancies in circumcised Jewish men
 +
|journal=J Urol
 +
|date=1973
 +
|volume=110
 +
|pages=696-702
 +
}}</ref>
  
−
Hellberg et al. (1986) identified tobacco use as another risk factor for cancer of the penis.<ref>Hellberg D, Valentin J, Eklund T, Staffan Nilsson. Penile cancer: is there an epidemiological role for smoking and sexual behavior. Brit Med J 1987;295(6609):1306-8</ref> The use of tobacco has since been a well established risk factor in cancer of the penis.<ref>Harish K, Ravi R. The role of tobacco in penile carcinoma. Brit J Urol 1995;75(3):375-377.</ref><ref>Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol 1987;138(4):861-2.</ref><ref>Maden C et al. History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer. Journal of the National Cancer Institute, vol. 85, no. 1., January 6, 1993, pp. 19-24.</ref>
+
Cold et al. (1997) reported a case of penile cancer in a 76-year-old white man."<ref name="cold1997">{{REFjournal
−
 
+
  |last=Cold
−
Other risks include poor hygiene, and an increased number of sexual partners (30 partners or more).<ref>•Brinton LA, Reeves WC, Brenes MM, et al. The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer 1989;44(2):199-203.</ref>
+
  |first=
−
 
+
  |init=CJ
−
[[Phimosis]] has been implicated as a risk factor in sexually active males, because a non-retractile foreskin may result in poor hygiene, and because men with phimosis are at higher risk for lichen sclerosus (also known as [[balanitis xerotica obliterans]]), which may also be a risk factor.<ref name="titlebmj.com Rapid Responses for Rickwood et al., 321 (7264) 792-793">{{REFweb
+
|author-link=
−
  | quote=
+
  |last2=Storms
−
  | url=http://bmj.bmjjournals.com/cgi/eletters/321/7264/792#110919
+
|first2=
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  | title=bmj.com Rapid Responses for Rickwood et al., 321 (7264) 792-793
+
  |init2=MJ
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  | last=
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  |author2-link=
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  | first=
+
  |last3=Van Howe
−
  | publisher=
+
  |first3=
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  | work=
+
  |init3=RJ
−
  | date=
+
|author3-link=Robert S. Van Howe
−
  | accessdate=2007-12-13
+
|etal=no
−
}}</ref> Adult males with a non-retractable foreskin who are sexually active may want to have the phimotic condition corrected. (For conservative treatment options, see [[phimosis]].)
+
|title=Carcinoma in situ of the penis in a 76-year-old circumcised man.
−
 
+
|trans-title=
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== Circumcision as prevention ==
+
|language=
−
 
+
|journal=J Fam Pract
−
The myth that circumcision rendered males immune to penile cancer was invented in 1932 by a man named Abraham L. Wolbarst, M.D.<ref>Wolbarst, AL. Circumcision and penile cancer. Lancet 1932; 150-3.</ref> Wolbarst wrote an article that was published in the Lancet in 1932, implicating human male [[smegma]] as carcinogenic.<ref>Wolbarst A. Circumcision and Penile Cancer. The Lancet, vol. 1 no. 5655 (January 16, 1932): pp. 150-153.</ref> His hypothesis had absolutely no basis in valid scientific and epidemiological research.<ref>Fleiss PM, Hodges F. Neonatal circumcision does not protect against cancer. BMJ 1996;312(7033):779-80.</ref> Wolbarst was directly responsible for proliferation of this myth, and all subsequent repetions of it can be traced to his opinion article, although Wolbarst himself advocated universal neonatal circumcision principally as a preventive for epilepsy, paralysis, and masturbation.<ref>Fleiss PM, Hodges F. Neonatal circumcision does not protect against cancer. BMJ 1996;312(7033):779-80.</ref>
+
|location=
−
 
+
|date=1997-04
−
Wolbarst's opinion piece led to the perpetuation of the myth that penile cancer could not happen to males that were circumcised in infancy. This myth was completely disproven when Boczko et al. reported the 9th documented case of penile cancer in a man who had been circumcised in infancy from the time of Wolbarst's opinion piece to the time of the report in 1968 (though they would maintain that "performing [circumcision] in infancy continues to be the most effective prophylactic measure against penile carcinoma").<ref>Boczko S, Freed S. Penile carcinoma in circumcised males. N Y State J Med 1979; 79(12):1903-4.</ref> Boczko et al. wrote: ''"The diagnosis in our patient was made late, as in the other cases reported, perhaps because the disease was presumed not to occur in those circumcised in infancy. This is clearly not so. Although rare, the diagnosis must be considered when evaluating a penile lesion even in a circumcised individual."''
+
|season=
−
 
+
|volume=44
−
In 1993, Christopher Maden, Ph.D., et al. reported a study in which 110 men with penile cancer, diagnosed from January 1979, to July, 1990, were interviewed. Of these 110 men, 22 had been circumcised at birth, 19 later in life, and 69 never.<ref>Poland R. The question of routine neonatal circumcision. New Engl J Med 1990; 322(18):1312-1314.</ref> As cases of penile cancer in circumcised men begin to accumulate<ref>Pec J Jr, Pec J Sr, Plank L, Plank J, Lazarova Z, Kliment J. Squamous cell carcinoma of the penis. Analysis of 24 cases. Int Urol Nephrol 1992; 24: 193-200.</ref><ref>Aynaud O, Ionesco M; Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74: 1762-7.</ref><ref>Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol 1986; 135: 283-5.</ref><ref>Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol 1987; 138: 861-2.</ref><ref>Windahl T, Hellsten S. Laser treatment of localized squamous cell carcinoma of the penis. J Urol 1995; 154: 1020-3.</ref><ref>Leiter E, Lefkovitis AM. Circumcision and penile carcinoma. N Y State J Med 1975; 75: 1520-2.</ref><ref>Onuigbo WI. Carcinoma of skin of penis. Br J Urol 1985; 57: 465-6.</ref><ref>Korczak D, Siegel Y, Lindner A. [Verrucous carcinoma of the penis.] Harefuah 1989; 117: 436-7.
+
|issue=
−
</ref><ref>Girgis AS, Bergman H, Rosenthal H, Solomon L. Unusual penile malignancies in circumcised Jewish men. J Urol 1973; 110: 696-702.</ref>, it becomes clear that the assertion that circumcision eliminates the risk of penile cancer is categorically false, although some circumcision advocates continue to make this assertion.
+
|article=
 +
|page=
 +
|pages=407-10
 +
|url=https://www.cirp.org/library/disease/cancer/vanhowe/
 +
|archived=
 +
|quote=
 +
|pubmedID=9108839
 +
|pubmedCID=
 +
|DOI=
 +
|doi=
 +
|accessdate=2023-09-05
 +
}}</ref> The medical literature contains numerous additional case reports of cancer in [[circumcised]] men.
  
 +
it becomes clear that the assertion that [[circumcision]] eliminates the risk of penile cancer is categorically false, although some circumcision advocates continue to make this assertion.
 
=== Discussion ===
 
=== Discussion ===
 +
Advocates of [[circumcision]] may yet point to the aforementioned studies and highlight that the incidence of penile cancer was still lower in the [[circumcised]] groups of men studied, than it was in the [[intact]] group, and that thus "a lowered risk of penile cancer is observed in circumcised men." It is important to remember when looking at the studies performed in the 1950s, that the octogenarians afflicted with penile cancer were born in the 1870s, when the circumcision rate in the United States was close to zero; the majority of men in that generation who were afflicted with cancer would be [[intact]]. The increased number of cases of penile cancer found in more recent studies is reflective of the steadily increasing circumcision rates in this country (37% of Maden's cases were [[circumcised]]). Using Maden's numbers and properly adjusting his control population to match the case population for age, there was no difference in risk of developing penile cancer between men who were circumcised and those who were not. HPV (the cause of genital warts) has been found in most cases of penile cancer. Genital warts are now more common in [[circumcised]] men <ref name="cook1994">{{REFjournal
 +
|last=Cook
 +
|init=LS
 +
|last2=Koutsky
 +
|init2=LA
 +
|last3=Holmes
 +
|init3=KK
 +
|title=Circumcision and sexually transmitted diseases
 +
|journal=Am J Public Health
 +
|date=1994
 +
|volume=84
 +
|pages=197-201
 +
}}</ref><ref name="cook1993"/> and HPV lesions are equally common in [[circumcised]] and [[intact]] men.<ref name="Aynaud etal 1994"/> As the number of [[circumcised]] men approaching the age at which penile cancer becomes evident (70s and 80s) it is quite likely that the vast majority of men developing penile cancer in the [[United States]] will be [[circumcised]].
  
−
Advocates of circumcision may yet point to the aforementioned studies and highlight that the incidence of penile cancer was still lower in the circumcised groups of men studied, than it was in the intact group, and that thus "a lowered risk of penile cancer is observed in circumcised men." It is important to remember when looking at the studies performed in the 1950s, that the octogenarians afflicted with penile cancer were born in the 1870s, when the circumcision rate in the United States was close to zero; the majority of men in that generation who were afflicted with cancer would be intact. The increased number of cases of penile cancer found in more recent studies is reflective of the steadily increasing circumcision rates in this country (37% of Maden's cases were circumcised). Using Maden's numbers and properly adjusting his control population to match the case population for age, there was no difference in risk of developing penile cancer between men who were circumcised and those who were not. HPV (the cause of genital warts) has been found in most cases of penile cancer. Genital warts are now more common in circumcised men <ref>Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health 1994; 84: 197-201. Cook LS. Koutsky LA. Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med 1993; 69: 262-264.</ref> and HPV lesions are equally common in circumcised and intact men.<ref>Aynaud O, Ionesco M; Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74: 1762-7.]</ref> As the number of circumcised men approaching the age at which penile cancer becomes evident (70s and 80s) it is quite likely that the vast majority of men developing penile cancer in the United States will be circumcised.
+
Reddy et al. (1975) examined the frequency of carcinoma of the penis from 32 hospitals in India and found a wide variation in incidence that could not be explained by the [[intact]] status of the Hindus or the [[circumcision]] practices of the Muslims.<ref name="reddy1975">{{REFjournal
−
 
+
|last=Reddy
−
Reddy et al. examined the frequency of carcinoma of the penis from 32 hospitals in India and found a wide variation in incidence that could not be explained by the intact status of the Hindus or the circumcision practices of the Muslims. <ref>Reddy CR, Raghavaiah NV, Mouli KC. Prevalence of carcinoma of the penis with special reference to India. Int Surg 1975, 60: 474-6.</ref> Finally, circumcision does not explain why Japan and Denmark have lower penile cancer rates than the United States when circumcision, especially infant circumcision, is not common in those two countries.<ref>Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis. A life-table analysis. Am J Dis Child 1980; 134: 484-6. Swafford TD. Circumcision and the risk of cancer of the penis [letter] Am J Dis Child 1985; 139: 112.</ref>
+
|init=CR
−
 
+
|last2=Raghavaiah
−
In "Circumcision: An American Health Fallacy," Edward Wallerstein writes: ''"If infant circumcision reduces penile cancer we could expect to see proportionately less penile cancer in circumcising nations as compared to noncircumcising ones. No such difference is found."'' Wallerstein reports that, for various years between 1966 and 1972, the annual rate of new cases of penile cancer was 0.8 for the United States (where circumcision rates are high), and 0.5 for Finland, 0.9 for Denmark and 1.1 for both Norway and Sweden (all of where circumcision rates are low). None of these differences is statistically significant.<ref>Wallerstein, Edward. Circumcision: An American Health Fallacy. Springer-Verlag, New York, 1980.</ref> Further, within the same time frame, both France and the United States had the same rate, 0.3, of deaths due to penile cancer.<ref>Hyman AB; Brownstein MH. Tyson's "Glands," Archives of Dermatology, vol. 99, no. 1 (January 1969): pp. 31-37</ref>
+
|init2=NV
−
 
+
|last3=Mouli
−
== Incidence of penile cancer ==
+
|init3=KC
−
 
+
|title=Prevalence of carcinoma of the penis with special reference to India
−
In North America the rate of penile cancer has been estimated to be 1 in 100,000<ref>Cutler SJ, Young JL Jr. Third national cancer survey: incidence data. Bethesda, Md. US Dept of Health, Education, and Welfare, Public Health Service, 1975</ref>. Maden et al reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations.<ref>Maden C, Sherman KJ, Beckman AM, Hislop TG, Teh CZ, Ashley RL, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. JNCI 1993;85:19-24</ref> Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.
+
|journal=Int Surg
−
 
+
|date=1975
−
Penile cancer is very rare in Europe and North America, occurring in about one in 100,000 men in the latter. It accounts for 0.2% of cancers and 0.1% of deaths from cancer amongst males in the United States. However, in some parts of Africa and South America it accounts for up to 10% of cancers in men.<ref name="titleACS :: What Are the Key Statistics About Penile Cancer?">{{REFweb
+
|volume=60
−
  | quote=
+
|pages=474-6
−
  | url=http://web.archive.org/web/20071030194444/http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_penile_cancer_35.asp?sitearea=
+
|pubmedID=54346
−
  | title=ACS :: What Are the Key Statistics About Penile Cancer?
+
|pubmedCID=
−
  | last=
+
|DOI=
−
  | first=
+
|doi=
−
  | publisher=
+
|accessdate=2023-09-08
−
  | work=
+
}}</ref> Finally, circumcision does not explain why Japan and [[Denmark]] have lower penile cancer rates than the [[United States]] when circumcision, especially infant [[circumcision]], is not common in those two countries.<ref name="kochen1980">{{REFjournal
−
  | date=2007-10-30
+
|last=Kochen
−
| accessdate=2007-12-13
+
|init=M
 +
|last2=McCurdy
 +
|init2=S
 +
|title=Circumcision and the risk of cancer of the penis. A life-table analysis
 +
|journal=Am J Dis Child
 +
|date=1980
 +
|volume=134
 +
|pages=484-6
 +
}}</ref><ref>{{REFjournal
 +
  |last=Swafford
 +
  |init=TD
 +
  |author-link=Thomas D. Swafford
 +
  |title=Circumcision and the risk of cancer of the penis [letter]
 +
  |journal=Am J Dis Child
 +
  |date=1985
 +
  |volume=139
 +
  |page=112
 
}}</ref>
 
}}</ref>
  
−
In Japan, Norway, and Sweden, the risk of penile cancer is about the same as in the US (1 in 100,000 per year).<ref>{{REFjournal
+
In "[[Circumcision: An American Health Fallacy]]," [[Edward Wallerstein]] writes: ''"If infant circumcision reduces penile cancer we could expect to see proportionately less penile cancer in circumcising nations as compared to noncircumcising ones. No such difference is found."'' Wallerstein reports that, for various years between 1966 and 1972, the annual rate of new cases of penile cancer was 0.8 for the [[United States]] (where circumcision rates are high), and 0.5 for [[Finland]], 0.9 for [[Denmark]] and 1.1 for both [[Norway]] and [[Sweden]] (all of where circumcision rates are low). None of these differences is statistically significant.<ref>{{WallersteinE 1980}}</ref> Further, within the same time frame, both France and the [[United States]] had the same rate, 0.3, of deaths due to penile cancer.<ref>{{REFjournal
−
  |last=Wallerstein
+
  |last=Hyman
−
  |first=E.
+
|init=AB
−
  |title=Circumcision. The uniquely American medical enigma
+
|last2=Brownstein
−
  |journal=Urol. Clin. North Am.
+
  |init2=MH
−
  |volume=12
+
  |title=Tyson's "Glands"
 +
  |journal=Archives of Dermatology
 +
  |volume=99
 
  |issue=1
 
  |issue=1
−
  |pages=123-32
+
|date=1969-01
−
  |url=
+
  |pages=31-37
 +
}}</ref>
 +
Rosemary Romberg (2021) explained:
 +
<blockquote>
 +
Both ''politics'' and ''economics'' are strongly involved in this issue. Far too often many choices in human health care have not centered on what is best for the individual. Instead they have centered on who is in ''control'' and who is getting ''paid''. A doctor is the person in ''control'' when he performs a circumcision. He cannot ''control'' whether or not that person is going to wash himself. Similarly, doctors get ''paid'' for doing circumcisions, but they do not get ''paid'' for telling people to wash.<ref name="romberg2021">{{REFbook
 +
|last=Romberg
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|first=Rosemary
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|init=
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|author-link=Rosemary Romberg
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|year=2021
 +
|title=Circumcision — The Painful Dilemma
 +
  |url=https://circumcisionthepainfuldilemma.wordpress.com/
 +
|work=
 +
|editor=[[Ulf Dunkel]]
 +
|edition=Second Edition, Revised
 +
|volume=
 +
|chapter=Conclusions
 +
|scope=
 +
|page=328
 +
|pages=
 +
|location=
 +
|publisher=Kindle
 +
|ISBN=23: 979-8683021252
 
  |quote=
 
  |quote=
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</blockquote>
  
 
== HPV vaccine ==
 
== HPV vaccine ==
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The main article for this is [[//en.wikipedia.org/wiki/HPV_vaccine HPV vaccine]] on Wikipedia.
 
The main article for this is [[//en.wikipedia.org/wiki/HPV_vaccine HPV vaccine]] on Wikipedia.
  
−
Infection with HPV is associated with some penile cancers.  A quadri-valent vaccine ([[Gardasil]]) to prevent infection by the four most common variants of HPV has been developed, successfully tested, and approved by the US [[Food and Drug Administration]] for females between the ages of 9 and 26, and as of 2009, males between the ages of 16 and 26.<ref name="titleAccess to articles : Nature Reviews Drug Discovery">{{REFjournal
+
Infection with human papilloma virus (HPV} is associated with many penile cancers.  A quadri-valent vaccine ([[Gardasil]]) to prevent infection by the four most common variants of HPV has been developed, successfully tested, and approved by the US [[Food and Drug Administration]] for females between the ages of 9 and 26, and as of 2009, males between the ages of 16 and 26.<ref name="Nature Reviews Drug Discovery">{{REFjournal
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  |last=Crum C, Jones C, Kirkpatrick P
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  |last=Crum
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|init=C
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|last2=Jones
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  |init3=P
 
  |title=Quadrivalent human papillomavirus recombinant vaccine
 
  |title=Quadrivalent human papillomavirus recombinant vaccine
 
  |journal=Nature reviews. Drug discovery
 
  |journal=Nature reviews. Drug discovery
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  |pubmedCID=
 
  |DOI=10.1038/nrd2117
 
  |DOI=10.1038/nrd2117
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  |date=August 2006
+
  |date=2006-08
 
  |accessdate=
 
  |accessdate=
−
}}</ref> Gardasil has been shown to also be effective in males, and has been approved by the FDA to be marketed as such.<ref name="Bloomberg">[http://www.bloomberg.com/apps/news?pid=20601202&sid=aajzweDaXZh0&refer=healthcare Cortez, Michelle Fay and Pettypiece, Shannon. "Merck Cancer Shot Cuts Genital Warts, Lesions in Men". ''Bloomberg News''. (Bloomberg.com) 13 Nov 2008.]</ref>
+
}}</ref> Gardasil has been shown to also be effective in males, and has been approved by the FDA to be marketed as such.<ref name="Bloomberg">{{REFnews
 +
|last=Cortez
 +
|first=Michelle Fay
 +
|last2=Pettypiece
 +
|first2=Shannon
 +
|url=http://www.bloomberg.com/apps/news?pid=20601202&sid=aajzweDaXZh0&refer=healthcare
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|title=Merck Cancer Shot Cuts Genital Warts, Lesions in Men
 +
|puglisher=Bloomberg News
 +
|website=Bloomberg.com
 +
|date=2008-11-13
 +
}}</ref> Two to three doses are necessary.
 +
 
 +
The Centers for Disease Control and Prevenntion (CDC) recommends that male and female children be vaccinated against HPV when they are eleven or twelve years old.<ref>{{REFweb
 +
|url=https://www.cdc.gov/hpv/
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|title=Human Papillomavirus (HPV)
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|last=
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|first=
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|init=
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|publisher=Centers for Disease Control and Prevention
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|accessdate=2023-09-06
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}}</ref>
  
 
{{SEEALSO}}
 
{{SEEALSO}}
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* [[Urethral cancer]]
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* [[Abraham L. Wolbarst]]
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* [[Cervical cancer]]
  
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{{LINKS}}
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|url=http://www.cirp.org/library/disease/cancer/
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|title=Penile cancer, cervical cancer, and circumcision
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|publisher=Circumcision Reference Library
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}}
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* {{REFweb
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|url=https://www.doctorsopposingcircumcision.org/for-professionals/alleged-medical-benefits/cancer-of-the-penis/
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|title=Cancer of the Penis
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|author-link=
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|publisher=[[Doctors Opposing Circumcision (D.O.C.)]]
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{{ABBR}}
 
{{REF}}
 
{{REF}}
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[[Category:Penile illness]]
  
 
[[Category:From Intactipedia]]
 
[[Category:From Intactipedia]]
 
[[Category:From IntactWiki]]
 
[[Category:From IntactWiki]]

Latest revision as of 10:56, 9 September 2023

Penile cancer is a malignant growth found on the skin or in the tissues of the penis. Squamous cell carcinoma usually originating in the glans or foreskin is by far the most common type, occurring in 9 out of 10 cases.[1] Penile cancer is extremely rare, and it tends to develop in men over the age of sixty.[2]

Incidence of penile cancer

In North America the rate of penile cancer has been estimated to be 1 in 100,000[3]. Maden et al. (1993) reported penile cancer among a fifth of elderly patients from rural areas who had been circumcised neonatally and had been born at a time when the rate of neonatal circumcision was about 20% in rural populations.[4] Their study also shows that the rate of penile cancer among men circumcised neonatally has risen in the United States relative to the rise in the rate of neonatal circumcision.

Penile cancer is very rare in Europe and North America, occurring in about one in 100,000 men in the latter. It accounts for 0.2% of cancers and 0.1% of deaths from cancer amongst males in the United States. However, in some parts of Africa and South America it accounts for up to 10% of cancers in men.[5]

In Japan, Norway, and Sweden, the risk of penile cancer is about the same as in the US (1 in 100,000 per year).[6]

Risk factors

The major risk factors for penile cancer are advanced age (greater than age 60), use of tobacco, and infection with human papilloma virus.

Circumcision myth

The myth that smegma was a carcinogenic, and thus that circumcision would render a man immune to penile cancer, was invented in 1932 by a defender of ritual circumcision named Abraham L. Wolbarst, who also believed that circumcision prevented venereal disease,[7] epilepsy, paralysis, and masturbation.[8] No laboratory or clinical research had been done on the subject at the time, however Wolbarst's myth found its way into early medical textbooks regardless. Although the smegma hypothesis was completely disproven by an exhaustive study by Reddy in 1963,[9] circumcision advocates continue to stubbornly repeat it.

The American Cancer Society (1996) pointed out that incidence of penile cancer is lower in nations that do not circumcise and urged the American Academy of Pediatrics not to promote child circumcision as a preventive against cancer.[10]

Infection with human papilloma virus

The link between the presence of human papillovirus (HPV) and genital cancer was established in the 1980s.[11][12][13][14][15][16] Poland identified human papilloma virus (HPV) types 16 and 18 as the cause of penile and cervical cancers in 1990, and that they could be spread by sexual contact.[17] At least one study suggests that circumcised men are at higher risk for HPV infection,[18] making being circumcised a risk factor.

Use of tobacco

Hellberg et al. (1986) identified tobacco use as another risk factor for cancer of the penis.[19] The use of tobacco has since been a well established risk factor in cancer of the penis.[20][21][22]

Other risks include poor hygiene, and an increased number of sexual partners (30 partners or more).[23]

Circumcision as a risk factor

Bissada et al. (1986) reported cancer forms on the circumcision scar.[24] The circumcision scar may provide an entry point for HIV. Circumcision should now be considered a risk factor for penile cancer.

Other risks

Phimosis has been implicated as a risk factor in sexually active males, because a non-retractile foreskin may result in poor hygiene, and because men with phimosis are at higher risk for lichen sclerosus (also known as balanitis xerotica obliterans), which may also be a risk factor.[25] Adult males with a non-retractable foreskin who are sexually active may want to have the phimotic condition corrected. (For conservative treatment options, see phimosis.)

Symptoms

Symptoms include redness, irritation, a sore or a lump on the penis.[26]

Pathology

  • A. Precancerous Dermatologic Lesions
  • B. Carcinoma in Situ (Bowen Disease, Erythroplasia of Queyrat)
  • C. Invasive Carcinoma of the Penis

Staging

Like many malignancies, penile cancer can spread to other parts of the body. It is usually a primary malignancy, the initial place from which a cancer spreads in the body. Much less often it is a secondary malignancy, one in which the cancer has spread to the penis from elsewhere. Doctors use the extent of metastasis to estimate what stage the disease is in, to aid in treatment decisions and prognosis. The stages are assessed as follows (Jackson's staging):

  • Stage I - Cancer has only affected the glans and/or foreskin.
  • Stage II - Cancer has spread to the shaft of the penis.
  • Stage III - Mobile (operable) inguinal lymph nodes.
  • Stage IV - Fixed (inoperable) inguinal lymph nodes or distant metastasis.
  • Recurrent - Cancer that has returned after treatment.

Prognosis can range considerably for patients, depending where on the scale they have been staged. Generally speaking, the earlier the cancer is diagnosed, the better the prognosis. The overall 5-year survival rate for all stages of penile cancer is about 50 percent.

Treatment

There are several treatment options for penile cancer, depending on staging. They include surgery, radiation therapy, chemotherapy, and biological therapy. The most common treatment is one of five types of surgery:

  • Wide local excision - The tumor and some surrounding healthy tissue are removed.
  • Microsurgery - Surgery performed with a microscope is used to remove the tumor and as little healthy tissue as possible.
  • Laser surgery - laser light is used to burn or cut away cancerous cells.
  • Circumcision - cancerous foreskin is removed.
  • Amputation (penectomy) - a partial or total removal of the penis, and possibly the associated lymph nodes.

Radiation therapy is usually used adjuvantly with surgery to reduce the risk of recurrence. With earlier stages of penile cancer, a combination of topical chemotherapy and less invasive surgery may be used. More advanced stages of penile cancer usually require a combination of surgery, radiation and chemotherapy. In addition to all the above, treatment of the underlying disease like Brucellosis, is important to limit disease recurrence.

Circumcision as prevention myth

The myth that circumcision rendered males immune to penile cancer was invented in 1932 by a New York doctor named Abraham L. Wolbarst, M.D.[a 1][27] Wolbarst wrote an article that was published in The Lancet in 1932, implicating human male smegma as carcinogenic.[27] His hypothesis had absolutely no basis in valid scientific and epidemiological research.[28] Wolbarst was directly responsible for proliferation of this myth, and all subsequent repetitons of it can be traced to his opinion article, although Wolbarst himself advocated universal neonatal circumcision principally as a preventive for epilepsy, paralysis, and masturbation.[28]

Wolbarst's opinion piece led to the perpetuation of the myth that penile cancer could not happen to males that were circumcised in infancy. This myth was completely disproven when Boczko et al. (1979) reported the 9th documented case of penile cancer in a man who had been circumcised in infancy from the time of Wolbarst's opinion piece to the time of the report in 1968 (though they would maintain that "performing [circumcision] in infancy continues to be the most effective prophylactic measure against penile carcinoma").[29] Boczko et al. (1979) wrote: "The diagnosis in our patient was made late, as in the other cases reported, perhaps because the disease was presumed not to occur in those circumcised in infancy. This is clearly not so. Although rare, the diagnosis must be considered when evaluating a penile lesion even in a circumcised individual."

In 1993, Christopher Maden, Ph.D.[a 2], et al. reported a study in which 110 men with penile cancer, diagnosed from January 1979, to July, 1990, were interviewed. Of these 110 men, 22 had been circumcised at birth, 19 later in life, and 69 never.[30] As cases of penile cancer in circumcised men begin to accumulate[31][32][33][34][35][36][37][38][39]

Cold et al. (1997) reported a case of penile cancer in a 76-year-old white man."[40] The medical literature contains numerous additional case reports of cancer in circumcised men.

it becomes clear that the assertion that circumcision eliminates the risk of penile cancer is categorically false, although some circumcision advocates continue to make this assertion.

Discussion

Advocates of circumcision may yet point to the aforementioned studies and highlight that the incidence of penile cancer was still lower in the circumcised groups of men studied, than it was in the intact group, and that thus "a lowered risk of penile cancer is observed in circumcised men." It is important to remember when looking at the studies performed in the 1950s, that the octogenarians afflicted with penile cancer were born in the 1870s, when the circumcision rate in the United States was close to zero; the majority of men in that generation who were afflicted with cancer would be intact. The increased number of cases of penile cancer found in more recent studies is reflective of the steadily increasing circumcision rates in this country (37% of Maden's cases were circumcised). Using Maden's numbers and properly adjusting his control population to match the case population for age, there was no difference in risk of developing penile cancer between men who were circumcised and those who were not. HPV (the cause of genital warts) has been found in most cases of penile cancer. Genital warts are now more common in circumcised men [41][18] and HPV lesions are equally common in circumcised and intact men.[32] As the number of circumcised men approaching the age at which penile cancer becomes evident (70s and 80s) it is quite likely that the vast majority of men developing penile cancer in the United States will be circumcised.

Reddy et al. (1975) examined the frequency of carcinoma of the penis from 32 hospitals in India and found a wide variation in incidence that could not be explained by the intact status of the Hindus or the circumcision practices of the Muslims.[42] Finally, circumcision does not explain why Japan and Denmark have lower penile cancer rates than the United States when circumcision, especially infant circumcision, is not common in those two countries.[43][44]

In "Circumcision: An American Health Fallacy," Edward Wallerstein writes: "If infant circumcision reduces penile cancer we could expect to see proportionately less penile cancer in circumcising nations as compared to noncircumcising ones. No such difference is found." Wallerstein reports that, for various years between 1966 and 1972, the annual rate of new cases of penile cancer was 0.8 for the United States (where circumcision rates are high), and 0.5 for Finland, 0.9 for Denmark and 1.1 for both Norway and Sweden (all of where circumcision rates are low). None of these differences is statistically significant.[45] Further, within the same time frame, both France and the United States had the same rate, 0.3, of deaths due to penile cancer.[46] Rosemary Romberg (2021) explained:

Both politics and economics are strongly involved in this issue. Far too often many choices in human health care have not centered on what is best for the individual. Instead they have centered on who is in control and who is getting paid. A doctor is the person in control when he performs a circumcision. He cannot control whether or not that person is going to wash himself. Similarly, doctors get paid for doing circumcisions, but they do not get paid for telling people to wash.[47]

HPV vaccine

The main article for this is [HPV vaccine] on Wikipedia.

Infection with human papilloma virus (HPV} is associated with many penile cancers. A quadri-valent vaccine (Gardasil) to prevent infection by the four most common variants of HPV has been developed, successfully tested, and approved by the US Food and Drug Administration for females between the ages of 9 and 26, and as of 2009, males between the ages of 16 and 26.[48] Gardasil has been shown to also be effective in males, and has been approved by the FDA to be marketed as such.[49] Two to three doses are necessary.

The Centers for Disease Control and Prevenntion (CDC) recommends that male and female children be vaccinated against HPV when they are eleven or twelve years old.[50]

See also

External links

Abbreviations

  1. ↑ REFweb Doctor of Medicine, Wikipedia. Retrieved 14 June 2021. In the United Kingdom, Ireland and some Commonwealth countries, the abbreviation MD is common.
  2. ↑ REFweb Doctor of Philosophy, Wikipedia. Retrieved 16 June 2021. (Also abbreviated as D.Phil.)

References

  1. ↑ REFweb Cancer Research UK: Types of penile cancer. Retrieved 24 June 2008.
  2. ↑ REFbook Frisch M: Penile Cancer, in: Cancer Epidemiology and Prevention. Thun M.J., Linet M.S., Cerhan J.S., Schottenfeld D. (ed.). Edition: 4. New York: Oxford University Press. Pp. 1029-1038. Retrieved 19 September 2020.
  3. ↑ REFdocument Cutler / Young Jr: Third national cancer survey: incidence data, US Dept of Health, Education, and Welfare, Public Health Service (Bethesda, MD). (1975).
  4. ↑ REFjournal Maden C, Sherman KJ, Beckman AM, Hislop TG, Teh CZ, Ashley RL, et al. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. JNCI. 1993; 85: 19-24. PMID. DOI. Retrieved 7 September 2023.
  5. ↑ REFweb (30 October 2007). ACS :: What Are the Key Statistics About Penile Cancer? (archive URL). Retrieved 13 December 2007.
  6. ↑ REFjournal Wallerstein E. Circumcision. The uniquely American medical enigma. Urol Clin North Am. February 1985; 12(1): 123-32. PMID. Retrieved 10 February 2020.
  7. ↑ REFjournal Wolbarst AL. Universal Circumcision as a Sanitary Measure. JAMA. 10 January 1914; 62(2): 92-97. DOI. Retrieved 6 September 2023.
  8. ↑ REFjournal Wolbarst AL. Circumcision and penile cancer. Lancet. 16 January 1932; 1(5655): 150-3. DOI. Retrieved 13 March 2022.
  9. ↑ REFjournal Reddy DG, Baruah IK. Carcinogenic Action of Human Smegma. Archives of Pathology. April 1963; 75(4): 414-420. PMID. Retrieved 6 September 2023.
  10. ↑ REFweb (16 February 1996). Letter to American Academy of Pediatrics, American Cancer Society. Retrieved 6 September 2023.
  11. ↑ REFjournal zur Hausen H. Genital papillomavirus infections. Prog Med Virol. 1985; 32: 15-21. PMID. Retrieved 7 September 2023.
  12. ↑ REFjournal Kaufman RH, Adam E. Herpes simplex virus and human papilloma virus in the development of cervical carcinoma. Clin Obstet Gynecol. 1986; 3: 678-692. PMID. Retrieved 7 September 2023.
  13. ↑ REFjournal McCance DJ, 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. PMID. DOI. Retrieved 8 September 2023.
  14. ↑ REFjournal Villa LL, Lopes A. Human papillomavirus DNA sequences in penile carcinomas in Brazil. Int J Cancer. 1986; 37(6): 853-5. PMID. Retrieved 8 September 2023.
  15. ↑ REFjournal McCance DJ. Human papillomaviruses and cancer. Biochem Biophys Acta. 1986; (823): 195-206. PMID. DOI. Retrieved 8 September 2023.
  16. ↑ REFjournal Barrasso R, De Brux J, Croissant O, et al. High prevalence of papillomavirus-associated penile intraepithelial neoplasia in sexual partners of women with cervical intraepithelial neoplasia. N Engl J Med. 8 October 1987; 317(15): 916-23. PMID. Retrieved 8 September 2023.
  17. ↑ REFjournal Poland RL. The question of routine neonatal circumcision. N Eng J Med. 1990; 322: 1312-5. PMID. DOI. Retrieved 7 September 2023.
  18. ↑ a b REFjournal Cook LS, Koutsky LA, Holmes KK. Clinical presentation of genital warts among circumcised and uncircumcised heterosexual men attending an urban STD clinic. Genitourin Med. 1993; 69: 262-4. PMID. PMC. DOI. Retrieved 7 September 2023.
  19. ↑ REFjournal Hellberg D, Valentin J, Eklund T, Nilsson S. Penile cancer: is there an epidemiological role for smoking and sexual behavior?. Brit Med J. 1987; 295(6609): 1306-8. PMID. PMC. DOI. Retrieved 8 September 2023.
  20. ↑ REFjournal Harish K, Ravi R. The role of tobacco in penile carcinoma. Brit J Urol. 1995; 75(3): 375-377. PMID. DOI. Retrieved 8 September 2023.
  21. ↑ REFjournal Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol. 1987; 138(4): 861-2. PMID. DOI. Retrieved 8 September 2023.
  22. ↑ REFjournal Maden C, et al. History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer. Journal of the National Cancer Institute. 6 January 1993; 85(1): 19-24. PMID. DOI. Retrieved 8 September 2023.
  23. ↑ REFjournal Brinton LA, Reeves WC, Brenes MM, et al. The male factor in the etiology of cervical cancer among sexually monogamous women. Int J Cancer. 1989; 44(2): 199-203. PMID. DOI. Retrieved 8 September 2023.
  24. ↑ REFjournal Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol. February 1986; 135(2): 283-5. PMID. DOI. Retrieved 10 February 2020.
  25. ↑ REFjournal Various authors. Rapid Responses for Rickwood et al. (archive URL). BMJ. 321(7264): 792-3. Retrieved 13 March 2022.
  26. ↑ REFweb Penis Cancer. Retrieved 24 June 2008.
  27. ↑ a b REFjournal Wolbarst AL. Circumcision and penile cancer. Lancet. 16 January 1932; 1(5655): 150-3. DOI. Retrieved 13 March 2022.
  28. ↑ a b REFjournal Fleiss PM, Hodges F. Neonatal circumcision does not protect against cancer. BMJ. 1996; 312(7033): 779-80.
  29. ↑ REFjournal Boczko S, Freed S. Penile carcinoma in circumcised males]. N Y State J Med. 1979; 79(12): 1903-4.
  30. ↑ REFjournal Poland R. The question of routine neonatal circumcision. New Engl J Med. 1990; 322(18): 1312-4. PMID. DOI. Retrieved 6 September 2023. }}
  31. ↑ REFjournal Pec Jr J, Pec Sr J, Plank L, Plank J, Lazarova Z, Kliment J. Squamous cell carcinoma of the penis. Analysis of 24 cases. Int Urol Nephrol. 1992; 24: 193-200.
  32. ↑ a b REFjournal Aynaud O, Ionesco M, Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer. 1994; 74: 1762-7.
  33. ↑ REFjournal Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol. 1986; 135: 283-5.
  34. ↑ REFjournal Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol. 1987; 138: 861-2.
  35. ↑ REFjournal Windahl T, Hellsten S. Laser treatment of localized squamous cell carcinoma of the penis. J Urol. 1995; 154: 1020-3.
  36. ↑ REFjournal Leiter E, Lefkovitis AM. Circumcision and penile carcinoma. N Y State J Med. 1975; 75: 1520-2.
  37. ↑ REFjournal Onuigbo WI. Carcinoma of skin of penis. Br J Urol. 1985; 57: 465-6.
  38. ↑ REFjournal Korczak D, Siegel Y, Lindner A. [Verrucous carcinoma of the penis]. Harefuah. 1989; 117: 436-7.
  39. ↑ REFjournal Girgis AS, Bergman H, Rosenthal H, Solomon L. Unusual penile malignancies in circumcised Jewish men. J Urol. 1973; 110: 696-702.
  40. ↑ REFjournal Cold CJ, Storms MJ, Van Howe RJ. Carcinoma in situ of the penis in a 76-year-old circumcised man.. J Fam Pract. April 1997; 44: 407-10. PMID. Retrieved 5 September 2023.
  41. ↑ REFjournal Cook LS, Koutsky LA, Holmes KK. Circumcision and sexually transmitted diseases. Am J Public Health. 1994; 84: 197-201.
  42. ↑ REFjournal Reddy CR, Raghavaiah NV, Mouli KC. Prevalence of carcinoma of the penis with special reference to India. Int Surg. 1975; 60: 474-6. PMID. Retrieved 8 September 2023.
  43. ↑ REFjournal Kochen M, McCurdy S. Circumcision and the risk of cancer of the penis. A life-table analysis. Am J Dis Child. 1980; 134: 484-6.
  44. ↑ REFjournal Swafford TD. Circumcision and the risk of cancer of the penis [letter]. Am J Dis Child. 1985; 139: 112.
  45. ↑ REFbook Wallerstein E (1980): Circumcision: An American Health Fallacy. Edition: Springer Series: Focus on Men. Vol. 1. Springer Pub Co. ISBN 978-0826132413.
  46. ↑ REFjournal Hyman AB, Brownstein MH. Tyson's "Glands". Archives of Dermatology. January 1969; 99(1): 31-37.
  47. ↑ REFbook Romberg, Rosemary (2021): Conclusions, in: Circumcision — The Painful Dilemma. Ulf Dunkel (ed.). Edition: Second Edition, Revised. Kindle. P. 328. ISBN 23: 979-8683021252. Retrieved 31 August 2023.
  48. ↑ REFjournal Crum C, Jones C, Kirkpatrick P. Quadrivalent human papillomavirus recombinant vaccine. Nature reviews. Drug discovery. August 2006; 5(8): 629-30. PMID. DOI.
  49. ↑ REFnews Cortez, Michelle Fay / Shannon Pettypiece (13 November 2008)."Merck Cancer Shot Cuts Genital Warts, Lesions in Men", Bloomberg.com.
  50. ↑ REFweb Human Papillomavirus (HPV), Centers for Disease Control and Prevention. Retrieved 6 September 2023.
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