Reports of circumcised men developing penile cancer

Reviewing the literature and the experience at our institution I have found at least 91 cases of circumcised men developing penile neoplasms. These include:

Maden C, Sherman KJ, Beckmann AM, Hislop TG, Teh CZ, Ashley RL, Daling JR. History of circumcision, medical conditions, and sexual activity and risk of penile cancer. J Natl Cancer Inst 1993; 85: 19-24. [41 cases]
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. [5 cases]
Aynaud O, Ionesco M; Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74: 1762-7. [16 cases]
Bissada NK, Morcos RR, el-Senoussi M. Post-circumcision carcinoma of the penis. I. Clinical aspects. J Urol 1986; 135: 283-5. [15 cases]
Rogus BJ. Squamous cell carcinoma in a young circumcised man. J Urol 1987; 138: 861-2. [1 case]
Windahl T, Hellsten S. Laser treatment of localized squamous cell carcinoma of the penis. J Urol 1995; 154: 1020-3. [4 cases]
Cupp MR, Malek RS, Goellner JR, Smith TF, Espy MJ. The detection of human papillomavirus deoxyribonucleic acid in intraepithelial, in situ, verrucous and invasive carcinoma of the penis. J Urol 1995; 154: 1024-9. [2 cases]

These articles all contain at least one case of a circumcised man developing penile cancer, however I do nothave the articles in hand to provide an exact number:

Boczko S, Freed S. Penile carcinoma in circumcised males. N Y State J Med 1979; 79: 1903-4.
Leiter E, Lefkovitis AM. Circumcision and penile carcinoma. N Y State J Med 1975; 75: 1520-2.
Onuigbo WI. Carcinoma of skin of penis. Br J Urol 1985; 57: 465-6.
Korczak D, Siegel Y, Lindner A. [Verrucous carcinoma of the penis.] Harefuah 1989; 117: 436-7.
Girgis AS, Bergman H, Rosenthal H, Solomon L. Unusual penile malignancies in circumcised Jewish men. J Urol 1973; 110: 696-702.

In addition:
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. [Reddy CR, Raghavaiah NV, Mouli KC. Prevalence of carcinoma of the penis with special reference to India. Int Surg 1975, 60: 474-6.]

In addition:
We have just begun review of our experience at the Marshfield Clinic in Wisconsin with 26 penile carcinoma cases. Of the first five cases reviewed, two of the men were circumcised. We hope to publish our series sometime in the next year. One of the men experienced a two year delay in having his cancer diagnosed because his urologist wrongly believed that circumcised men cannot develop penile cancer. The diagnosis was made by a dermatologist. We hope we don't get sued.

It is important to remember when looking at the studies performed in the 1950s(which most procircumcision zealots such as Schoen and Wiswell like to cite) those octogenarians were born in the 1870s when the circumcision rate in the United States was close to zero. 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 [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.] and HPV lesions are equally common in circumcised and intact men [Aynaud O, Ionesco M; Barrasso R. Penile intraepithelial neoplasia. Specific clinical features correlate with histologic and virologic findings. Cancer 1994; 74: 1762-7.]. 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.

Finally, circumcision does not explain why Japan and Denmark have lower penile cancer rates than the United States when those two countries do not practice circumcision. [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.]

Robert S. Van Howe, MD FAAP

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