Commentary on "Countries with high circumcision prevalence have lower prostate cancer mortality".

Dear Editor,

I have read with interest and some amazement the article of Dr. Wachtel and coworkers describing a hypothetical benefit of male circumcision (MC) on prostatic cancer (PC) mortality rates.1 The issue is old and going back to 1951.2 Unfortunately, the authors have omitted the literature during the last 65 years which was not able to prove that MC would protect against PC mortality.3456789 Wachtel and coworkers draw their study data from different heterogeneous sources and different years without testing if they describe items of comparable population groups.

Most strikingly, the results of the paper do neither support the headline of the article nor support the conclusions. The MC-rates in Europe and Southeast Asia are far lower than in the United States. The authors, however, found lower PC mortality in Europe and Southeast Asia when compared to the United States (OR 0.6 and 0.42). It is hard to understand how this can lead to the conclusion that “thus, prostate cancer mortality is significantly lower in countries in which MC prevalence exceeds 80%.” Especially as PC mortality in the Eastern Mediterranean countries and Sub-Saharan region with MC rates >80% clearly exceed the European rates with an MC prevalence below 20%.

The evaluation of PC mortality compared to MC prevalence shows that PC is similar from 0 to 80% MC but lower in the 80%–100% MC group. It should at least be discussed which protective factor would not be effective until 80% but would have a significant effect above this level. The more likely explanation is that the databases describe populations and countries with medical, hygienic, and social differences which have a greater influence on PC mortality than has MC.

According to the results of Wright and coworkers,10 a number of about 250 MC's would be necessary to prevent one case of PC death.

COMPETING INTERESTS

The author declared no competing interests.