Cervical Cancer & Circumcision

A research summary brief by the Circumcision Information and Resource Pages
[Note: DrMomma.org does not advocate for the use of Gardasil (an HPV vaccine) in minor aged girls.]

In February 1996, representatives of the American Cancer Society stated in a letter to the American Academy of Pediatrics:

The American Cancer Society does not consider routine circumcision to be a valid or effective measure to prevent [genital] cancers. Research suggesting a pattern in the circumcision status of partners of women with cervical cancer is methodologically flawed, outdated and has not been taken seriously in the medical community for decades.

The hypothesis that cervical cancer is caused by smegma of the male foreskin was invented in 1954 by Wynder. His study was found to be invalid, because most of the cervical cancer patients in his study incorrectly reported that their husbands were intact. These women had no idea whether their husbands were circumcised or not. They gave the answer they thought the doctor wanted to hear. Wynder later recognized and admitted the error in 1960. (1) This hypothesis was formally and scientifically disproven in 1962 by Stern. (2)

Stern and Neely examined some of the early research on this subject (2):

Since the recommendation had been made that circumcision should be used as a preventative measure against cancer of the cervix, we sought further confirmation of this hypothesis. An almost ideal population was that of the well women attending a cancer detection facility, where the population was split almost equally between women whose husbands were circumcised and those whose husbands were not. The discovery rate for cancer of the cervix among non-Jewish women whose marital partners were circumcised was no different from the rate among non-Jewish women with intact husbands. Further, the use of a sheath contraceptive by the marital partner, which has an effect equivalent to circumcision in that the cervix is protected from contact with the smegma, was found not to be associated with rate differences for cancer of the cervix.

This study, more than the others, exposed the myth that the presence of a foreskin or smegma had any association with the incidence of cancer of the cervix. (See also 3-5)

Ho et al. (6) have established that co-factors such as cigarette smoking may be necessary to advance HPV infected cervical epithelial cells toward a cancerous condition. Ho et al. (3) have also suggested that high levels of antioxidants in the blood serum may provide some protection, although more study is needed.

Walboomers reported that HPV DNA is found in more than 99.7 percent of cervical cancer cells in 1999. HPV infection is a necessary condition for cervical cancer. (7)

The known etiologies of cervical cancer are:

*early onset of sexual activity

*number of sexual partners

*smoking

*the presence of HPV (8)

Based on currently available evidence, it would be mistaken to suggest an association between cervical cancer and the presence of the foreskin in the male partner.

The New England Journal of Medicine published an article by Castelsagué and others in 2002. This article purported to show that circumcision reduced the risk of infection to the wives of circumcised men. This article has experienced severe and unrelenting criticism due to numerous methodological flaws, its conflict with other published research, and other research by the same authors that showed that different types of HPV were found in husbands and wives. (9-14) Editorial problems previously had been reported at The New England Journal of Medicine. The publication of this flawed article may have been the result of those editorial problems.

See the National Organization of Circumcision Information and Resource Centers position statement for more information on cervical cancer and circumcision. (12)

Menczer reports that genetics, not male circumcision, limits the incidence of cervical cancer in Jewish women. (15) The argument that Jewish women have a lower incidence of cervical cancer because their husbands are circumcised appears to be destroyed by this finding.

Vaccine.

Infection with human papillomavirus (HPV) is a necessary condition for the formation of cervical cancer. (7) A bi-valent vaccine that offers substantial protection from infection with HPV has been successfully tested. (16) It is expected that approval of this vaccine will receive approval from regulatory authorities and that when it will greatly reduce the incidence of HPV infection, cervical cancer, and death when vaccination against HPV becomes widespread. (17) Male circumcision has never been proved to offer any real protection against HPV infection in the female partner, but even if it did, it still would not be necessary because the vaccine will offer protection. (18)

References

1) Ernest L. Wynder; Samuel D. Licklider. "The Question of Circumcision," Cancer, vol. 13, no. 3 (May-June 1960): pp. 442-445.


2) Elizabeth Stern; Peter M. Neely. "Cancer of the Cervix in Reference to Circumcision and Marital History," Journal of the American Medical Women's Association, vol. 17, no. 9 (September 1962): pp. 739-740.


3) American Cancer Society. Dispelling Miscommunications: Statement on Penile Cancer. ACS News Today, Atlanta, (1998).


4) Ho GY, Kadish AS, Burk RD, et al. HPV 16 and cigarette smoking as risk factors for high-grade cervical intra-epithelial neoplasia. Int J Cancer 1998;78(3):281-5.


5) Ho GY, Palan PR, Basu J, et al. Viral characteristics of human papillomavirus infection and antioxidant levels as risk factors for cervical dysplasia . Int J Cancer 1998;78(5):594-9.


6) Cold CJ, Storms MR, Van Howe RS. Carcinoma in situ of the penis in a 76-year-old circumcised man. J Fam Pract 44(4), April 1997, pp. 407-410. [Demonstrates: Circumcision has no statistically-significant effect on the rate of penile cancer, when Maden's data are properly adjusted for age.]


7) Maiche AG. Epidemiological aspects of cancer of the penis in Finland. Eur J Cancer Prev 1992;1(2):153-8.


8) 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.


9) Dillner J, von Krogh G, Horenblas S, Meijer CJ. Etiology of squamous cell carcinoma of the penis. Scand J Urol Nephrol Suppl 2000;(205):189-93.


10) Wyatt SW, Lancaster M, Bottorff D, Ross F. History of tobacco use among Kentucky women diagnosed with invasive cervical cancer: 1997-1998. J Ky Med Assoc 2001;99(12):537-9.


11) Oliver JC, Oliver RT, Ballard RC. Influence of circumcision and sexual behaviour on PSA levels in patients attending a sexually transmitted disease (STD) clinic. Prostate Cancer Prostatic Dis 2001:4(4):228-31.


12) Milos M. NEJM Cervical Cancer Study Has Fatal Flaws. BMJ 2002 Rapid Response Letter, 27 April 2002.


13) Travis J. Misuse of the medical literature. BMJ 2002 Rapid Response Letter, 29 April 2002.


14) Comments on Male Circumcision, Penile Human Papillomavirus Infection, and Cervical Cancer. New Engl J Med 2002;47(18):1448.


15) National Organization of Circumcision Information Resource Centers. Position Statement on the Use of Male Circumcision to Prevent Cervical Cancer. San Anselmo: National Organization of Circumcision Information Resource Centers, 2002.


16) Menczer J. The low incidence of cervical cancer in Jewish women: Has the puzzle finally been solved? IMAJ 2004;5:120-3.


17) Harper DM, Franco EL, Wheeler C, et al. Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial. Lancet 2004;364(9447):1757-65.


18) Crum C, Jones C, Kirkpatrick P. Fresh from the pipeline: Quadrivalent human papillomavirus recombinant vaccine. Nat Rev Drug Discov 2006;5:629-630.