A Study of the Aetiology of Carcinoma of the Cervix Uteri

THE relative infrequency of cancer of the uterine cervix in Jewish women compared with women of other races has interested epidemiologists since the beginning of the century, but has not yet been explained. The average annual number of cases per 100,000 Jewish women in Israel over a 19-year period has been shown by Hochman, Ratzkowski and Schreiber (1955) to be 2-2, while the rate per 100,000 women elsewhere ranges from 17 in Sweden to 44 in a group of 10 cities in the U.S.A. Reasons for the disparity have been sought in genetics, in the Jewish ritual laws governing sexual hygiene and in the possible protective effects of universal male circumcision. Support for the circumcision hypothesis is found in the lower frequency of cancer of the cervix in other populations who practise circumcision when compared with populations who do not. Again, penile cancer is rare in those circumcised at an early age, suggesting some carcinogenic property of smegma and an association between poor penile hygiene and cancer of the cervix. It is not easy to isolate the effect of circumcision from that of many simultaneous variables and environmental differences between population groups. Circumcision has been included among the factors considered in several careful studies of the aetiology of this disease, but its importance is still in doubt. The difficulty in finding out if there is a lower rate of cancer of the cervix among wives of circumcised non-Jewish men lies in ascertaining accurately who is or is not effectively circumcised, and in obtaining the information for all of the sexual partners of each woman. While the second difficulty seems insurmountable, the present study attempts to compare, by physical examination in 110 cases, the circumcision status of present husbands of women with pre-cinical and clinically diagnosed cancer of the cervix and husbands of matched controls. Even such a small number is of interest when the facts about circumcision are definitely established. Moreover, the study has shown what degree of co-operation can be obtained in such an inquiry and what error there would be were examination dispensed with and the husband's or wife's report relied on. PREVIOUS WORKIn population groups other than Jewish, practising circumcision, lower rates of cervical cancer have been noted when compared with groups in the same general environment who do not practise circumcision. Examples have come from the 10

Section: Resultssupporting

confidence: 92%

Section: Contraceptives and Circumcisionmentioning

confidence: 99%

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Circumcision and Cancer of the Cervix

Aitken-Swan¹,

Baird²

1965

“…Many authors have obtained data which suggest that this is so (Boyd and Doll, 1964;Melamed et al, 1969;Worth and Boyes, 1972;Boyce et al, 1977;Collette et al, 1978). The reported effect has, however, usually been small.…”

Section: Discussionmentioning

confidence: 99%

Neoplasia and dysplasia of the cervix uteri and contraception: a possible protective effect of the diaphragm

Wright¹,

Vessey²,

Kenward³

et al. 1978

Self Cite

100

Summary.-Among the 17,032 women included in the Oxford-Family Planning Association contraceptive study, 65 developed biopsy proven cervical neoplasia (including dysplasia) prior to 1 September 1977. The incidence rate in diaphragm users (0.17 per 1000 woman-years of observation) was much lower than the rates in oral contraceptive users or intrauterine device users (0.95 and 0-87 respectively). This difference could not be explained in terms of confounding variables, nor was it attributable to a lower frequency of cervical smearing among diaphragm users within the clinics.Detailed information about age at first intercourse, numbers of sexual partners and the frequency of cervical smearing outside the clinics was obtained from 52 of the women with cervical neoplasia and 139 matched controls. Diaphragm users were less likely to have had coitus at an early age and had had materially fewer sexual partners-tian users of the other two methods of contraception. After adjusting for the effects of these variables, however, the risk of cervical neoplasia in diaphragm users was still only about one quarter that in the users of the other methods. Patterns of smearing varied little between users of the various contraceptive methods.Smoking emerged as a major "risk factor" for cervical neoplasia in this study. This probably implies that the smoking habit reflects some important aspect of sexual behaviour relevant to the production of the disease that we have been unable to measure.

“…If these lesions are part of a single continuum, the risk factors identified for cervical dysplasia and carcinoma in situ would be expected to be similar to those identified for invasive cervical cancer. The latter indicate the importance of sexual behaviour, and include early age at first sexual intercourse, multiple sexual partners, early marriage, multiple marriages and early age at first pregnancy (Wynder et al, 1954;Boyd & Doll, 1964;Stewart et al, 1966;Rotkin, 1967; Kessler, 1976;Singer, 1975).…”

mentioning

confidence: 99%

Characteristics of women with dysplasia or carcinoma in situ of the cervix uteri

Harris¹,

Brinton²,

Cowdell³

et al. 1980

Self Cite

234

Summary.-To identify risk factors for various cervical abnormalities, 237 women with abnormal cervical smears and 422 control women were interviewed. Cervical biopsy specimens taken from the patients with abnormal smears were reviewed according to standard criteria by one pathologist and classified as follows: 65 carcinoma in situ, 81 severe dysplasia, 44 mild dysplasia and 47 normal histology. Factors associated with risk of mild dysplasia, severe dysplasia and carcinoma in situ were similar to those previously identified for invasive carcinoma, and included age at first intercourse, multiple sexual partners and pregnancy outside marriage. Analysis to disentangle correlated factors revealed that number of sexual partners exerted effects independently of age at first intercourse, whereas the reverse was not true. This finding fails to support suggestions that adolescence is a period when the cervix is most vulnerable to the effects of sexual behaviour. Other factors relating to risk of cervical abnormalities were smoking and use of oral contraceptives. It was not possible to show that these relationships were incidental, but further investigation is required to establish whether they are causal.