CIRCUMCISION, PROSTATE CANCER, and AUTISM: Misleading Headlines and Selective Reporting

A few months ago, in reference to the publication of an article by Brian Morris on Mayo Clinic Proceedings, we argued that:

Media headlines are used to manipulate the general opinion by using the more dramatic claims from the abstract to embed them in the collective consciousness. Most people will not read past the headlines, and will reach their conclusions based on this limited information. Few reporters and authors dare to criticize peer reviewed publications.

We recently saw this phenomenon at work again,  regarding a possible link between circumcision and prostate cancer. A combination of fear-mongering and wishful thinking are being used to promote America’s favorite forced genital surgery. We are also listening to the deafening silence regarding a study that correlated the use of paracetamol during routine infant circumcisions with increasing rates of autism, arguably because the media has no interest in reporting negative side effects from circumcision procedures.

Prostate Cancer

Let’s take a look at the headlines:

June 4th, 2014. Fox News: Circumcision Linked to lower risk of prostate cancer 

May 30, 2014. Daily Mail. Circumcision reduces the risk of prostate cancer by up to 60% – but is most effective when done after the age of 35

Apr 7, 2014. Science Daily: Circumcision could prevent prostate cancer

Apr 11, 2014. Men’s Health. Should You Get Circumcised? New research suggests a surprising benefit to getting snipped—but here’s why we’re skeptical

Jun 5, 2014. Jerusalem Post: Study links circumcision, lower rates of prostate cancer

May 29, 2014. Medline Plus: Lower Risk of Prostate Cancer Seen in Circumcised Blacks: Study. But findings still preliminary, need confirmation (linked by National Institutes of Health)

Apr 8th, 2014. Prostate Cancer UK: Not enough evidence to suggest that circumcision could reduce risk of prostate cancer

All of these headlines and more, are in reference to a single paper:

March 24, 2014
BJU. Circumcision and prostate cancer: a population-based case-control study in Montréal, Canada
Spence AR1, Rousseau MC, Karakiewicz PI, Parent ME.

 

Marie-Élise Parent

Marie-Élise Parent

So, you can see, dear readers, the disparity in the headlines. “Could prevent“, “Linked“, “Reduces the risk“, “Links“, “Lower risk is seen“, “Not enough evidence“. Some of the headlines appear to be conclusive (“reduces the risk“, “linked“, “links“), some are conditional (“could prevent“) and a few are skeptical (“not enough evidence“). Depending on which media outlet you read, you may get a different impression just from reading the headline.

So what does the study really say?

The results of the study read: “Circumcised men had a slightly lower risk, albeit not statistically significant, of developing prostate cancer“. Among the conclusions: “Circumcision appeared to be protective only among Black men, a group that has the highest rate of disease.

In Sense About Science, Dr Matthew Hobbs, Deputy Director of Research at Prostate Cancer UK responded to the study saying:

Although this study appears to show that circumcision after the age of 35 could reduce your risk of prostate cancer, the evidence presented is nowhere near strong enough that men should begin to consider circumcision as a way to prevent the disease. While the total sample studied was large, the number of men who had been circumcised after the age of 35 was very small, so this should not be seen as strong evidence of an association. There was no statistically significant association between prostate cancer and circumcision for men circumcised at all other ages. No reason was collected for circumcision, so we can’t say if the association is with circumcision later in life or with whatever causes men to have circumcisions after that age. It is also highly likely that diet, lifestyle, socioeconomic status and healthcare behaviours may have played a role in skewing these results.” – See more at: http://www.senseaboutscience.org/for_the_record.php/148/quotcircumcision-cuts-risk-of-prostate-cancer-by-45quot#sthash.w3uMSk3Y.dpuf

While the main benefit boasted in the study has been for black males circumcised over the age of 35, Fox News cites Dr. Christopher Cooper, a professor and urologist at the University of Iowa, declaring that ”The number of black men studied was too small for any conclusions to be drawn. Only 103 of the participants with prostate cancer were black men, and only 75 of the healthy men in the comparison group were black.“. The Fox News article finishes quoting one of the researchers, Marie-Elise Parent, saying: “We are too early in the game to make it a public recommendation. It could be that in the future it will be confirmed that it’s a good thing and may have an added protection from other diseases“.

Being early, however, didn’t stop the media from planting the idea that circumcision prevents prostate cancer, through the use of misleading and manipulative headlines.

The Daily Mail also cites Dr. Parent saying: “We do not know why a protective effect was observed for men circumcised after the age of 35. These men may have had a pathologic condition of the foreskin that lead to them being circumcised“.

Medline Plus quotes Dr. Parent cautioning that the black men in the study, mainly of French descent, may not reflect black men as a whole. And she said the study included few men who were circumcised at a later age, so that finding is potentially questionable. (Only potentially?)

Some of the articles indicate that the researchers suspect the connection may be a “lower rate among circumcised men of sexually transmitted diseases (STD), which raise prostate cancer risk” but they are not conclusive.

To this, Fox News cites Dr. Christopher Cooper, a professor and urologist at the University of Iowa indicating that the number of black men studied was too small for any conclusions to be drawn, and saying: “The STD mechanism is possible but quite a stretch“. He pointed out that there were factors the researchers could not control in the study, such as how honest participants were about having STDs or, among the men circumcised as adults, the reason for their circumcision.

Medline Plus cites Dr. Stephen Freedland, urologist and associate professor of surgery and pathology at the Duke University School of Medicine in Durham, N.C., pointing out that men circumcised after age 35 are unusual. “They’re usually older guys who are sick and have medical problems,” he said. The study findings as a whole aren’t convincing, Freedland added, especially since it included relatively few black men — just 178 of more than 3,100 participants. “I don’t think we’ll be recommending massive circumcisions to prevent prostate cancer,” he said. “And men shouldn’t go around thinking, ‘I’m circumcised, therefore I’m safe from prostate cancer.‘”

Men’s Health adds a healthy dose of skepticism: “…if this study was done in a healthy population, you might get different results.

What is important to know is that the authors of the study do not explain why there would be such a protective effect, do not claim their results to be statistically significant, and furthermore acknowledge that the sample of black males over 35 was small. So, in other words, this study is very far from being conclusive, or even useful for the general public at all. If anything, this study could motivate further studies, but as for being applicable right now, it is not, and it would be irresponsible to act based on it. The media circus around this overall pointless study is atrociously misleading.

Autism

In the meantime, Environmental Health published a study last year about prenatal and perinatal analgesic exposure and autism. This study found correlations between indicators of prenatal and perinatal paracetamol exposure and autism/ASD. While the available data cannot provide strong evidence of causality, biologic plausibility is provided by a growing body of experimental and clinical evidence linking paracetamol metabolism to pathways shown to be important in autism and related developmental abnormalities.

While the abstract and title themselves do not specify circumcision, there is a detailed analysis of circumcision rates in the full text of the study. As our readers may remember, anesthesia during neonatal circumcisions was not common until a 1997 randomized controlled trial had to be halted due to trauma from pain. Lander et al’s early terminated study suggested that pain control should be administered prior to circumcision and that ring block was the most effective method.

Fast-forward to 2013, Bauer and Kriebel analyzed country-level data for the years 1997-2006, and found a strong correlation (r = 0.98) between circumcision and autism spectrum disorder prevalence rates for boys born after 1995, around the time when circumcision guidelines began recommending analgesia for routine infant circumcision. The slope of this trend for 9 countries with available data indicates that a change of 10% in the population circumcision rate was associated with an increase in autism/ASD prevalence of 2.01/1000 persons (95% CI: 1.68 to 2.34).

Again, when evaluating circumcision data for the United States, it is sobering to remember that approximately 1.2 million baby boys are circumcised every year. Could the use of paracetamol be causing autism and autism spectrum disorders in 2,400 baby boys annually?

A comparison of autism rates in boys and girls  found that male to female prevalence ratio increased from 3.9 to 1 prior to 1995, to 5.6 to 1 after 1995. The researchers suggested biological plausibility based on the infant’s lower capacity to metabolize drugs due to the underdevelopment of the glucuronidation pathway and inefficiency and immaturity in renal function.

So, basically we find two positions, one that circumcision without anesthetics is severely traumatic, and another one, that commonly used analgesia can increase rates of autism.

In spite of this strong data, practically no media outlets published any articles about this study and its implications on newborn circumcision.

In Summary

In summary, we have two studies that looked at correlations. One was not statistically significant; the other was. One did not offer a biological plausibility, the other one did.

And yet, which one got extensive media coverage? The one that suggested a benefit from newborn circumcision.

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