Table of Contents  
Year : 2016  |  Volume : 18  |  Issue : 6  |  Page : 950-951

Reply to Letter by Dr. Christoph Kupferschmid: Commentary on "Countries with high circumcision prevalence have lower prostate cancer mortality"

1 Texas Tech University Health Sciences Center, Lubbock, Texas, USA
2 School of Medical Sciences, University of Sydney, Sydney, New South Wales, Australia

Date of Submission05-Apr-2016
Date of Acceptance13-May-2016
Date of Web Publication22-Jul-2016

Correspondence Address:
Prof. Brian J Morris
School of Medical Sciences, University of Sydney, Sydney, New South Wales
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1008-682X.184997

Rights and Permissions

How to cite this article:
Wachtel MS, Yang S, Morris BJ. Reply to Letter by Dr. Christoph Kupferschmid: Commentary on "Countries with high circumcision prevalence have lower prostate cancer mortality". Asian J Androl 2016;18:950-1

How to cite this URL:
Wachtel MS, Yang S, Morris BJ. Reply to Letter by Dr. Christoph Kupferschmid: Commentary on "Countries with high circumcision prevalence have lower prostate cancer mortality". Asian J Androl [serial online] 2016 [cited 2021 Aug 1];18:950-1. Available from: - DOI: 10.4103/1008-682X.184997

Dear Editor,

We thank Dr. Kupferschmid for his interest in our study, which examined male circumcision (MC) and prostate cancer mortality.[1],[2] Considerable strong evidence has been accumulated since 1951.[3] Most of his references[4],[5],[6],[7],[8],[9],[10] do not address MC and the risk of death from prostate cancer. That is a different question than MC and the risk of developing prostate cancer, which none of his references validly assess. One reference addressed bacterial colonization,[6] not prostate cancer. Another[7] concerned sexually transmitted infections and prostate cancer. The US article he claims calculated number of circumcisions required to circumvent one prostate cancer death[11] had no death statistics. Since 14% of American men get prostate cancer and the Wright study found circumcision reduced risk by 13% in Caucasian and 36% in African American men, 54 Caucasian and 19 African American men would need to be circumcised prior to sexual debut to prevent one prostate cancer diagnosis.

Epidemiological studies in and of themselves can no more prove MC reduces prostate cancer mortality than they can prove cigarette smoking increases lung cancer mortality. They do, however, provide evidence scientists and officials might use to direct scientific investigation and government policy. We specifically stated that our findings to do not prove a causal relationship.[1]

Dr. Kupferschmid asserts our study used data from "different heterogeneous sources and different years." Each information source provisioned estimates for a particular year for prostate cancer mortality rates,[12] MC rates,[13] gross national incomes per capita and male life expectancies at birth,[14] and proportions of Muslims[15] and Jews in countries.[16]

Dr. Kupferschmid infers we evaluated differences among continents without taking into account potential biases. Vital, in our view, was taking into account differences among large geographic regions that might have biased the analysis of countries' mortality rates. Evidence of differences in cancer incidence and other relevant matters among continents is readily available.[17],[18],[19],[20] Using the WHO region as a covariate mitigated potential study bias arising from factors unrelated to MC. In our study, the "Americas" is not only limited to the USA, where MC is common, but also includes Central and South America, where MC is low.

Our study[1] took into account male life expectancy at birth and gross national income per capita. These covariates in part adjust for factors such as access to clean water and medical care. Higher-income countries have increased levels of prostate cancer, possibly due to sedentary lifestyle, obesity, and high red meat consumption, as we discussed.[1] Differences in proportions of Muslims and Jews, while of direct importance as respects MC, also reflect differences in dietary habits, as we discussed.[1] Social factors, a concern of Dr. Kupferschmid, were taken into account.

With these factors taken into account, our analysis revealed an association between increased MC rates and decreased prostate cancer mortality rates that could not be explained by chance.[1] The three categories used for MC prevalence, 0%-19%, 20%-80%, and 80%-100%, were designated by the WHO.[13] The threshold for significant protection against prostate cancer mortality could be well below 80% and requires further research.

Since more men die with prostate cancer than die of it, death from prostate cancer is a harder endpoint. By revealing an association of MC with prostate cancer mortality, our study adds to the existing data.

  Competing Interests Top

All authors declare no competing interests.

  References Top

Wachtel MS, Yang S, Morris BJ. Countries with high circumcision prevalence have lower prostate cancer mortality. Asian J Androl 2016; 18: 39.  Back to cited text no. 1
Kupferschmid C. Commentary on "Countries with high circumcision prevalence have lower prostate cancer mortality." Asian J Androl 2016. Doi: 10.4103/1008-682X.182816.  Back to cited text no. 2
Ravich A, Ravich RA. Prophylaxis of cancer of the prostate, cervix and penis by circumcision. NY State J Med 1951; 51: 1519-21.  Back to cited text no. 3
Kaplan GW, O′Connor VJ Jr. The incidence of carcinoma of the prostate in Jews and Gentiles (research letter). JAMA 1966; 196: 123-4.  Back to cited text no. 4
Gibson E. Carcinoma of the prostate in Jews and uncirumcised gentiles. BJU 1954; 26: 227-9.  Back to cited text no. 5
Lai FC, Kennedy WA, Lindert KA, Terris MK. Effect of circumcision on prostatic bacterial colonization and subsequent bacterial seeding following transrectal ultrasound-guided prostate biopsies. Tech Urol 2001; 7: 305-9.  Back to cited text no. 6
Rosenblatt KA, Wicklund KG, Stanford JL. Sexual factors and the risk of prostate cancer. Am J Epidemiol 2001; 153: 1152-8.  Back to cited text no. 7
Rotkin ID. Studies in the epidemiology of prostate cancer: expanded sampling. Cancer Treat Rep 1977; 61: 173-80.  Back to cited text no. 8
Jackson MA, Kovi J, Heshmat MY, Ogunmuyiwa TA, Jones GW, et al. Characterization of prostatic carcinoma among blacks: a comparison between a low incidence area, Ibadan, Nigeria and a high incidence area, Washington, DC. Prostate 1980; 1: 185-205.  Back to cited text no. 9
Wynder EL, Mabuchi K, Whitmore WF. Epidemiology of cancer of the prostate. Cancer 1971; 28: 344-60.  Back to cited text no. 10
Wright JL, Lin DW, Stanford JL. Circumcision and the risk of prostate cancer. Cancer 2012; 118: 4437-43.  Back to cited text no. 11
Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, et al. GLOBOCAN 2012: Estimated Cancer Incidence, Mortality, and Prevalence Worldwide in 2012. Lyon, France: International Agency for Research on Cancer; 2014.  Back to cited text no. 12
World Health Organization and Joint United Nations Programme on HIV/AIDS. Global map of male circumcision prevalence at country level, as of December 2006. Male circumcision: global trends and determinants of prevalence, safety and acceptability. Geneva, Switzerland: World Health Organization; 2007.  Back to cited text no. 13
World Bank. World Bank Open Data. 2014 ed. New York, United States: The World Bank Group; 2014. Available from:  Back to cited text no. 14
Pew Research Religion and Public Life Project. The Future of the Global Muslim Population. Washington, DC: Pew Research Center; 2011.  Back to cited text no. 15
Della Pergola S. World Jewish Population, 2010. Storrs, Connecticut: University of Connecticut; 2010.  Back to cited text no. 16
Martel-Jantin C, Filippone C, Tortevoye P, Afonso PV, Betsem E, et al. Molecular epidemiology of merkel cell polyomavirus: evidence for geographically related variant genotypes. J Clin Microbiol 2014; 52: 1687-90.  Back to cited text no. 17
Piel FB, Tatem AJ, Huang ZJ, Gupta S, Williams TN, et al. Global migration and the changing distribution of sickle haemoglobin: a quantitative study of temporal trends between 1960 and 2000. Lancet Glob Health 2014; 2: E80-9.  Back to cited text no. 18
Mendizabal AM, Younes N, Levine PH. Geographic and income variations in age at diagnosis and incidence of chronic myeloid leukemia. Int J Hematol 2016; 103: 70-8.  Back to cited text no. 19
Mahdavifar N, Ghoncheh M, Pakzad R, Momenimovahed Z, Salehiniya H. Epidemiology, incidence and mortality of bladder cancer and their relationship with the development index in the world. Asian Pac J Cancer Prev 2016; 17: 381-6.  Back to cited text no. 20

This article has been cited by
1 Expertise and Ideology in Statistical Evaluation of Circumcision for Protection against HIV Infection
Brian J. Morris,Gia Barboza,Richard G. Wamai,John N. Krieger
World Journal of AIDS. 2017; 07(03): 179
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Competing Interests

 Article Access Statistics
    PDF Downloaded264    
    Comments [Add]    
    Cited by others 1    

Recommend this journal