Should routine neonatal circumcision be a policy to prevent penile cancer? | Opinion: No

Routine neonatal circumcision remains a controversial topic. The most recent Canadian Paediatric Society does not recommend routine circumcision of every newborn male (1). And although prior statements from the American Academy of Pediatrics recommended against circumcision, the most recent recommendation states that circumcision outweigh the risk and the procedure’s benefits justify it for families who want it (2). The benefits mentioned by the American Academy of Pediatrics included prevention of urinary tract infections, transmission of sexually transmitted infections, and penile cancer. Prevention of penile cancer may be related to increasing daily hygiene and decreasing sexually transmitted infections such as human papilloma virus (HPV) in circumcised males. However, with improvements in daily hygiene and sexually transmitted infection prevention strategies, neonatal circumcision may not be critical for the prevention of penile cancer, especially in western countries. The association between lack of circumcision and penile cancer has been well documented (3). A meta-analysis found a strong protective effect of childhood circumcision on invasive penile cancer in 3 studies (OR 0.33; 95% 0.13-0.83) (3). However, in other studies when analyses were restricted to boys without a history of phimosis, the meta-analysis found that the protective effect of childhood circumcision on invasive disease no longer persisted (3). In addition, penile cancer continues to be one of the rarer malignancies in the world. In the United States where circumcision is prevalent, the rarity of disease is highlighted by its decreasing incidence. An analysis from the Surveillance, Epidemiology and End Results (SEER) database showed that the penile cancer incidence decreased to 0.58 per 100,000 in 1993-2002 from 0.84 per 100,000 in 1973-1982 in the United States (4). However, there is also a similar trend in countries with low circumcision rates such as Denmark and Finland (5, 6). In Denmark, penile cancer risk decreased from 1.15 per 100,000 in the 1940s to 0.82 per 100,000 in the late 1980s (5). Finland reported an incidence rate of 0.5 per 100,000 (6). Coupled with the rarity of penile cancer and conflicting evidence in the literature, it is hard to justify routine neonatal circumcision for all healthy males, including those without any preputial abnormalities, solely for the prevention of penile cancer. Despite its rarity, there are several common factors that have been implicated to cause penile cancer. Factors resulting in phimosis, balanitis, and smegma have been associated with penile cancer in a meta-analysis (7). This has often been attributed to the DiffereNce Of OpiNiON