Changes

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.}}</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}}</ref><ref>{{REFjournal |last=McCance |init=DJ, |last2=Kalache |init2=A., |last3=Ashdown |init3=K, et al. [ |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}}</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.}}</ref><ref>{{REFjournal |last=McCance |init=DJ. |title=Human papillomaviruses and cancer. '' |journal=Biochem Biophys Acta'' |date=1986; |issue=823: |pages=195-206}}</ref><ref>{{REFjournal |last=Barrasso |init=R, |last2=De Brux |init2=J, |last3=Croissant |init3=O, et al. |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 Oct 8;-10-08 |volume=317( |issue=15): |pages=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 name="poland1990">{{REFjournal |last=Poland |init=RL. [ |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.}}</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}}</ref> making being circumcised a risk factor.

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 Nilsson. [ |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}}</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.}}</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.}}</ref><ref>{{REFjournal |last=Maden |init=C et al. |etal=yes |title=History of Circumcision, Medical Conditions, and Sexual Activity and Risk of Penile Cancer. '' |journal=Journal of the National Cancer Institute'', vol. |volume=85, no. |issue=1., January 6, |date=1993, pp. -01-06 |pages=19-24.}}</ref>

Other risks include poor hygiene, and an increased number of sexual partners (30 partners or more).<ref>•Brinton {{REFjournal |last=Brinton |init=LA, |last2=Reeves |init2=WC, |last3=Brenes |init3=MM, et al. |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.}}</ref>

[[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">{{REFwebREFjournal |quoteurl=http://web.archive.org/web/20080513042221/http://bmj.bmjjournals.com/cgi/eletters/321/7264/792 |urlREM=http://web.archive.org/web/20080513042221/http://bmj.bmjjournals.com/cgi/eletters/321/7264/792#110919 |archived=yes |title=bmj.com Rapid Responses for Rickwood et al., 321 (7264) 792-793 |last=Various authors

|publisherjournal=BMJ |websitevolume=321 |dateissue=7264 |pages=792-3 |accessdate=20072022-1203-13

The myth that circumcision rendered males immune to penile cancer was invented in 1932 by a New York doctor named [[Abraham L. Wolbarst]], {{MD}}<refname="Wolbarst 1932">{{REFjournal |last=Wolbarst, |init=AL |author-link=Abraham L. Wolbarst |title=Circumcision and penile cancer. '' |journal=Lancet'' |date=1932; -01-16 |volume=1 |issue=5655 |pages=150-3.}}</ref> Wolbarst wrote an article that was published in ''The Lancet'' in 1932, implicating human male [[smegma]] as carcinogenic.<ref>name="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.<refname="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>Fleiss PM, Hodges F. [http://www.cirp.org/library/disease/cancer/fleiss/ Neonatal circumcision does not protect against cancer]. ''BMJ'' name="FleissPM HodgesFM 1996;312(7033):779-80.<"/ref>

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."''

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'' |date=1990; |volume=322( |issue=18): |pages=1312-1314.4}}</ref> As cases of penile cancer in circumcised men begin to accumulate<ref>{{REFjournal |last=Pec Jr |init=J Jr, |last2=Pec Sr |init2=J Sr, |last3=Plank |init3=L, |last4=Plank |init4=J, |last5=Lazarova |init5=Z, |last6=Kliment |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><refname="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>, 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.

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 O, Ionesco M; Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer etal 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 |init=CR, |last2=Raghavaiah |init2=NV, |last3=Mouli |init3=KC. |title=Prevalence of carcinoma of the penis with special reference to India. '' |journal=Int Surg'' |date=1975, |volume=60: |pages=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 name="kochen1980">{{REFjournal

|pages=484-6.

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=Hyman |init=AB; |last2=Brownstein |init2=MH. |title=Tyson's "Glands," '' |journal=Archives of Dermatology'', vol. |volume=99, no. |issue=1 (January |date=1969): pp. -01 |pages=31-37}}</ref>

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 Jr. |title=Third national cancer survey: incidence data. |location=Bethesda, Md. {{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, et al. [ |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}}</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="titleACS :: What Are the Key Statistics About Penile Cancer?">{{REFweb

|journal=Urol. Clin. North Am.

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

}}</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 and |last2=Pettypiece, |first2=Shannon. { |url=http://www.bloomberg.com/apps/news?pid=20601202&sid=aajzweDaXZh0&refer=healthcare |title=Merck Cancer Shot Cuts Genital Warts, Lesions in Men]. '' |puglisher=Bloomberg News''. ( |website=Bloomberg.com) |date=2008-11-13 Nov 2008.]}}</ref> Two to three doses are necessary.