Cervical Cancer

It is now known that the primary risk factor for cancer of the cervix is infection with human papilloma virus (HPV).[144] Only a handful of the hundred or so types of HPV are carcinogenic, with HPV 16 and HPV 18 associated with 70% of cervical cancers.[145] Behavioral risks such as age at sexual debut, the number of partners, and partners’ sexual behavior are associated with an increased risk of HPV infection.[146,147] Smoking is an important co-factor.[148]

The HIM (HPV Infection in Men) study showed that HPV is just as prevalent in circumcised as in intact males.[149] In this study, intact males showed faster clearance of the oncogenic (cancer-causing) HPV strains than did circumcised males, which could correlate to decreased transmission of oncogenic HPV from intact males to females.

There is no clear evidence that male circumcision decreases the risk of HPV infection in female partners, as studies have produced conflicting results. In a study of female university students in Washington State, circumcision status of the male partner was not associated with incident HPV infection over a mean follow-up time of 41 months.[150] A subsequent study, carried out in Uganda in conjunction with the HIV RCTs, found a lower rate of “high-risk” HPV strains, at 24 months, in women whose partners were circumcised at the beginning of the trial versus those whose partners had not been circumcised.[151] Although cervical cancer was not tracked as an outcome, this study has been used to support the claims of circumcision as a preventative for cervical cancer. The Ugandan HPV study suffers from numerous methodological flaws.[152] As with the HIV trials, these include lead-time bias and a high rate of loss to follow-up. The vaginal swabs analyzed were self-collected, a sub-standard technique potentially increasing rates of false positives and false negatives. Most tellingly, the study found no association between the male partner’s circumcision status and the presence of HPV types 16 and 18, the ones most likely to cause cervical cancer.

Sixteen studies have attempted to demonstrate a connection between cervical cancer in women and the circumcision status of their male sexual partners; all of them have failed.[153-168] One of these, by Castellsagué et al.,[153] has been repeatedly cited as proof of the connection between circumcision status and cervical cancer. Yet, in fact, the study was unable to show a significant association, except in a small subset of women who had partners with high-risk sexual behaviors. Again, serious methodological problems were present, with inappropriate design elements and analysis (described elsewhere [78,152]), further undermining the results.

Given all of the above, it is safe to say that cervical cancer has no appreciable link to male circumcision status. Furthermore, safe and effective vaccines are now available for adolescent and young adult females and males to help protect against HPV and, subsequently, cervical cancer in women, and various other cancers in men.[169,178] But even if the claims about the presence of the foreskin causing cervical cancer were true, it would be ethically and legally impermissible to circumcise non-consenting minors on this account, because the person bearing the risk would not be the person receiving the benefit.[170,171]

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References

78. Van Howe RS. Human papillomavirus and circumcision: a meta-analysis. J Infect. 2007;54(5):490-6.
144. Bosch FX, Lorincz A, Muñoz N, Meijer CJLM, Shah KV. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55:244-265.
145. HPV and cancer. National Cancer Institute website. Reviewed 2015 Feb 19.
146. Chelimo C, Wouldes TA, Cameron LD, Elwood JM. Risk factors for and prevention of human papillomaviruses (HPV), genital warts and cervical cancer. J Infect. 2013;66(3):207-17.
147. Ribeiro AA, Costa MC, Alves RR, Villa LL, Saddi VA, Carneiro MA, et al. HPV infection and cervical neoplasia: associated risk factors. Infect Agent Cancer. 2015;10:16.
148. Roura E, Castellsagué X, Pawlita M, Travier N, Waterboer T, Margall N, et al. Smoking as a major risk factor for cervical cancer and pre-cancer: results from the EPIC cohort. Int J Cancer. 2014;135(2):453-66.
149. Albero G, Castellsagué X, Lin HY, Fulp W, Villa LL, Lazcano-Ponce E, et al. Male circumcision and the incidence and clearance of genital human papillomavirus (HPV) infection in men: the HPV Infection in men (HIM) cohort study. BMC Infect Dis. 2014;14:75.
150. Winer RL, Lee S-K, Hughes JP, Adam DE, Kiviat NB, Koutsky LA. Genital human papillomavirus infection: incidence and risk factors in a cohort of female university students. Am J Epidemiol. 2003;157:218-26. Errata 2003;157:858.
151. Wawer MJ, Tobian AAR, Kigozi G, Kong X, Gravitt PE, Serwadda D, et al. Effect of circumcision of HIV-negative men on transmission of human papillomavirus to HIV-negative women: a randomised trial in Rakai, Uganda. Lancet. 2011;377:209-18.
152. Van Howe RS. Human papillomavirus and circumcision: the story beyond the tip. Academia website. Presented at the 13th International Symposium on Genital Autonomy and Children’s Rights, Boulder (CO); 2014 Jul 24.
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164. Agarwal SS, Sehgal A, Sardana S, Kumar A, Luthra UK. Role of male behavior in cervical carcinogenesis among women with one lifetime sexual partner. Cancer. 1993;72:1666-9.
165. Rotkin ID. A comparison review of key epidemiological studies in cervical cancer related to current searches for transmissible agents. Cancer Res. 1973;33:1353-67.
166. Stern E, Dixon WJ. Cancer of the cervix — a biometric approach to etiology. Cancer. 1961;14:153-60.
167. Kmet J, Damjanovski L, Stucin M, Bonta S, Cakmakov A. Circumcision and carcinoma colli uteri in Macedonia, Yugoslavia. Results from a field study. Br J Cancer. 1963;17:391-9.
168. Jones EG, MacDonald I, Breslow L. A study of epidemiologic factors in carcinoma of the uterine cervix. Am J Obstet Gynecol. 1958;76:1-10.
169. The Future II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. New Engl J Med. 2007;356(19):1915-27.
170. Waldeck SE. Using male circumcision to understand social norms as multipliers. 72 University of Cincinnati L. Rev. 455 (2003).
171. World Medical Association. Declaration of Helsinki. Ethical principles for medical research involving human subjects. Ferney-Voltaire (France): World Medical Association; 2013.
178.  National Center for Immunization and Respiratory Diseases. Human papillomavirus (HPV). Centers for Disease Control and Prevention website. Last reviewed 2019 Aug 15.

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