Carcinoma in situ of the penis in a 76-year-old circumcised man

Journal of Family Practice, April, 1997 by Christopher J. Cold, Michelle R. Storms, Robert S. Van Howe

A commonly held misperception in modern medicine is that circumcised men cannot develop neoplasms of the penis. (1) This misperception can be traced to a single 1932 article by Wolbarst, (2) a pro-circumcision advocate who also proclaimed circumcision as the cure for everything from masturbation to epilepsy to infant death. (3) This often cited paper based its conclusion on gathered reports of penile cancer from hospitals. No attempt was made to confirm circumcision status, and no control group was employed. None of the cases of penile cancer occurred in Jewish men circumcised at birth, prompting Wolbarst to conclude that circumcision prevented penile cancer. Until recently, this conclusion has not been properly studied of challenged. As circumcision gained popularity early in this century, the number of circumcised men reaching the age when penile cancer becomes apparent is rapidly increasing. Concomitantly, the number of circumcised men with penile cancer is already beginning to increase. (4) The following report demonstrates the potential damage resulting from this misperception.

* CASE REPORT

A 72-year-old white man presented to his physician in August 1992 with several millimeters of what was described in the chart as "white erythema" on the right glans penis. The lesion had been treated by a urologist with "creams." The patient was referred again to the urologist, but delayed the appointment until his follow-up cystoscopy for a papillary, grade 2, transitional-cell bladder carcinoma, which had been diagnosed in 1984. The erythematous patch was noted on the glans again by his physician in May 1994. In August 1995, at the age of 76 years, the patient was referred to a dermatologist, whose biopsy showed a squamous cell carcinoma in situ (Bowen's disease). A wide local excision was performed. No further evidence of disease has been identified in the first 6 months of clinical follow-up.

Significant past medical history included nonrecurrent bladder carcinoma, left hemicolectomy in 1964 for colon adenocarcinoma, excision of a rectal tubulovillous adenoma in 1994, benign prostatic hypertrophy status post-transuretheral resection of prostate, prostatourethritis in 1965, and hepatitis A with jaundice in 1942. He has been followed at the Marshfield Clinic in Marshfield, Wisconsin, since 1928.

He is of German descent and has lived his entire life in Marathon County, Wisconsin, as a dairy farmer. He was married in 1951 and had no sexual relationships outside his marriage. He has a 23-pack-year history of cigarette smoking but quit in 1959 and reports drinking an occasional beer. His circumcision status was not documented in the chart. After a review of the chart, the patient was contacted and he confirmed that he had been circumcised as long as he could remember.

* DISCUSSION

Cancer of the penis is an extremely rare malignancy with a predicted lifetime risk of 1 in 1437 men in the United States (5) and 1 in 1694 in Denmark, (6) representing 0.09% of all cancers and 0.16% of cancers in the male adult. (5) The risk factors for penile cancer (Table) include genital warts, (7,8) smoking, (8,9) past sexually transmitted diseases, (7,10) a sexual relationship outside marriage, (7) multiple sexual partners, (8) poor genital hygiene, (7,8,11,12) phimosis, (7-10,13) previous genital conditions (including urinary tract infection, genital warts, yeast infections, chlamydia, genital crabs, gonorrhea, genital herpes, syphilis, genital ulcers of sores), (7) penile rash (which lasted longer than 1 month) or penile tear, (8) chewing tobacco or areca nut, using snuff, (9) and postnatal circumcision. (7,8) Of these risk factors, a history of genital warts appears to be the most significant, leading experts to identify human papillomavirus (HPV) as the most common causative factor in penile cancer. (14)

Interestingly, genital warts ate now more common in circumcised men, (15) and HPV-associated lesions are equally prevalent in circumcised and intact men. Penile intraepithelial neoplasia, although found rarely, is slightly more common in men with foreskins. (16) In one published series of 11 men with carcinoina in situ of the penks, 10 had been circumcised as infants. (17)

The role of circumcision in preventing penile cancer has recently been called into question. (18) In addition to several publications documenting penile cancer in circumcised men, (19-26) a recent case-control study of 110 men with penile cancer from the Pacific Northwest revealed that 41 (37%) had been circumcised. (8) Relative to men circumcised at birth, the risk for penile cancer was 3.04 times as great among men who were never circumcised and 3.55 times as great among men who were circumcised after the neonatal period. The magnitude of risk for developing penile cancer was similar in smokers, but a history of multiple sexual partners or genital warts were the strongest risk factors (Table). While neonatal circumcision may play a small role in preventing penile carcinoma, 20% of the patients in this study were circumcised at birth. (8) Unfortunately, this study did not control well for age. When the control group was properly adjusted for age, there was no difference between the case group and control group in circumcision status.