Neonatal Circumcision: Cost-Effective Preventive Measure or “the Unkindest Cut of All”?

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C or surgical removal of the penile foreskin, is the subject of a cost-utility analysis appearing in this issue of Medical Decision Making. In an Egyptian bas-relief dating back to roughly 4000 BC, one patient appears willing to undergo the procedure. His more reluctant companion seems to require physical restraint, and this divergence of opinion presages the controversies still surrounding this procedure. It is not known to what degree routine circumcision (performed as a preventive rather than a therapeutic measure) favorably or unfavorably affects the risks of mechanical, inflammatory, infectious, and neoplastic processes, not to mention sexual sensation in males and their partners. The most serious potential complications of circumcision can be tragic but are fortunately rare. The advisability of this procedure has been addressed in countless letters, case reports, and, of necessity, observational studies of variable methodological rigor. These discussions are far too numerous to even begin recounting here. However, the volume of ink and effort devoted to them affirms that “the history of these few millimeters of skin is utterly epochal and fascinating.” Most reviewers concede that there is no conclusive medical evidence of either net benefit or net harm. Neither the American Academy of Pediatrics (AAP) nor the Canadian Paediatric Society (CPS) still recommends circumcision as a routine procedure, with CPS being a bit less enthusiastic. Both bodies recommend that parents be provided with balanced information on the procedure’s potential benefits and risks, and both acknowledge that there are religious, ethnic, and sociocultural considerations that tend to drive the final decision anyway. If circumcision is performed, it has been recommended that the procedure be accompanied by documented informed consent, as well as by adequate analgesia. Multistate administrative data from the Federal Healthcare Cost and Utilization Project (HCUP) indicate that 1.2 million males (59% of all US male newborns and 86% of those without a complicating diagnosis) were circumcised at birth in 2000. Figures are felt to be somewhat lower in Canada, and considerably lower elsewhere in the world. It is difficult to isolate costs specifically attributable to circumcisions performed during the birth admission. Nonetheless, the volumes of procedures performed make the aggregate “up front” and potential “downstream” costs (so to speak) of various circumcision strategies an important area to study. This discussion of Van Howe’s article may be prefaced with a review of the few formal cost analyses of circumcision that preceded it. A 1984 Canadian study estimated the mean costs of neonatal circumcision at Can$38.32 per case. Through compounding at 4% annually, this amount would have been worth $272 at age 50. Neonatal circumcision was assumed to prevent the 2 penile cancer cases estimated to occur otherwise per 100,000 50-year-old men per year. The modeled cost was Can$13.6 million per cancer case averted, and the authors concluded that “until demonstrated otherwise, prophylactic neonatal circumcision should be regarded as cosmetic surgery, paid for directly by parents wishing it.” A 1991 cost-utility analysis arbitrarily assigned utilities to death (0), penile cancer (0.5), other penile problems such as phimosis (0.99), and survival without such problems (1.0). No disutilities were assigned