I cannot leave Dr Jones' commentary in the NZMJ (30 April 2010) to go unchallenged, as he was responding to my letter in the NZMJ (19March 2010). In that letter I explained why the allegations that there was an ‘experiment' at National Women's Hospital (NWH) were false and I now wish to elaborate on my argument.For 20 years, New Zealanders have been led to believe there were two groups of women at NWH managed for CIN, one treated and one untreated, the latter having much higher rates of cancer.I reiterate my position; there never was an ‘Unfortunate Experiment', in which ‘Frankenstein Doctors', ‘withholding treatment', led women ‘like lambs to the slaughter'...as NWH treatment has been described.I quote again the Cartwright Inquiry:1 "...the 1984 McIndoe Paper distinguishes between two groups , and 22% of those whose abnormalities were untreated developed invasive cancer." The 131 women who were retrospectively allocated to group two by McIndoe/Jones in 1984 had had 228 major treatments ( initial cone biopsy 88, hysterectomy 33, or later management with 78 cone biopsies or 29 hysterectomies). How can this be misconstrued as no treatment? Dr Jones appears now to be attempting to move the discussion away from ‘treated vs untreated patients' to ‘adequate vs inadequate treatment'. Dr Jones refers to ‘inadequacy of treatment' yet even the McIndoe Paper2 p454 categorically states: "The 131 patients continued to produce abnormal cytology, irrespective of initial management." Does Dr Jones now acknowledge that New Zealand was misled: that Cartwright ‘got it wrong'....it was not ‘untreated patients' but ‘treated patients with different outcomes'? That is not how it was portrayed and that is a very different story. To quote Jones' own reference, Soutter:3 "After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 women years, until at least 20 years after treatment." and; " There was no statistically significant difference in the incidence of invasive recurrence between those series in which women were treated with hysterectomy and those in which one of the local, conservative methods of treatment was used." In other words, despite ‘adequate treatment', including hysterectomy, there is still a failure rate, that appears to continue for years. Dr Jones then asks why so many women got cancer, quoting 1:20 for his paper, but 1:200 for the rest of the World. Was treatment therefore ‘inadequate', as judged by the high rates for invasion in the McIndoe/Jones Paper? When results differ markedly from other comparable studies, by a factor of 10 in this case, one should confirm if the figures quoted and calculations are correct, and not a source of error. Were the McIndoe/Jones figures correct? I believe they are not reliable. A review of all cases of CIS seen at NWH from 1955-1986 was undertaken by M. Jamieson and A. Macintosh, (senior cancer specialists at NWH) and accepted by the Cartwright Inquiry (Source: Dr G Collison, NWH, Auckland, NZ, A Position Paper, July 1988, referenced in Cartwright Report). This review found 1222 cases from 1955-1976 and 1815 from 1977-1986. Thirty-two patients were identified as having invasive genital tract disease following persistent CIS of cervix and eight of those patients had died of genital tract cancer by the end of 1986. Astonishingly, these results were simply ignored by the Inquiry...Yet they were not rejected as incorrect. The results do however give a very different set of statistics. In fact, only 32 cancers over 30 years in 3037 patients. This gives cancer rates of 1% which are comparable to other studies. For example, Kolstad4 treated 1121 women with CIN of whom 12 developed invasive cancer. (about 1%). Soutter,3 also noted that the groups containing a high proportion of women with CIN 3 had a higher rate of invasive recurrence, than those with lesser grades.. Jamieson and Macintosh, like McIndoe/Jones, were analysing data from women who had been diagnosed with CIN 3, as did Kolstad, but many other studies included all CIN cases, so one would expect better figures in those groups. In the 1960s and 70s there was a change in the management of CIN, and at NWH and other places there were heated debates as to how ‘conservative' one could be. Learning curves of clinical management involve positive and negative outcomes.In this case unnecessary hysterectomy vs invasive disease, as treatment changed from obligatory hysterctomy in the 1950s to the more conservative approach now used. I do not hold with the Cartwright conclusion that the doctors at NWH withheld treatments as an experiment, which as recently as 2009 was described in the NZ Health Research Council's Ethical Notes...as ‘similar to Nazi experiments', and which resulted in excessive cancers. I believe Dr Green was determined not to do unnecessary radical surgery. Dr McIndoe believed in more invasive treatment; both were doing their best to avoid women getting invasive cancer—and importantly both were driven by a desire to do the best for their patients. Dr Helen Overton Vejle Hospital Denmark

I cannot leave Dr Jones' commentary in the NZMJ (30 April 2010) to go unchallenged, as he was responding to my letter in the NZMJ (19March 2010). In that letter I explained why the allegations that there was an ‘experiment' at National Women's Hospital (NWH) were false and I now wish to elaborate on my argument.For 20 years, New Zealanders have been led to believe there were two groups of women at NWH managed for CIN, one treated and one untreated, the latter having much higher rates of cancer.I reiterate my position; there never was an ‘Unfortunate Experiment', in which ‘Frankenstein Doctors', ‘withholding treatment', led women ‘like lambs to the slaughter'...as NWH treatment has been described.I quote again the Cartwright Inquiry:1 "...the 1984 McIndoe Paper distinguishes between two groups , and 22% of those whose abnormalities were untreated developed invasive cancer." The 131 women who were retrospectively allocated to group two by McIndoe/Jones in 1984 had had 228 major treatments ( initial cone biopsy 88, hysterectomy 33, or later management with 78 cone biopsies or 29 hysterectomies). How can this be misconstrued as no treatment? Dr Jones appears now to be attempting to move the discussion away from ‘treated vs untreated patients' to ‘adequate vs inadequate treatment'. Dr Jones refers to ‘inadequacy of treatment' yet even the McIndoe Paper2 p454 categorically states: "The 131 patients continued to produce abnormal cytology, irrespective of initial management." Does Dr Jones now acknowledge that New Zealand was misled: that Cartwright ‘got it wrong'....it was not ‘untreated patients' but ‘treated patients with different outcomes'? That is not how it was portrayed and that is a very different story. To quote Jones' own reference, Soutter:3 "After the first year following treatment for CIN, the rate of invasive disease remained about 56 per 100,000 women years, until at least 20 years after treatment." and; " There was no statistically significant difference in the incidence of invasive recurrence between those series in which women were treated with hysterectomy and those in which one of the local, conservative methods of treatment was used." In other words, despite ‘adequate treatment', including hysterectomy, there is still a failure rate, that appears to continue for years. Dr Jones then asks why so many women got cancer, quoting 1:20 for his paper, but 1:200 for the rest of the World. Was treatment therefore ‘inadequate', as judged by the high rates for invasion in the McIndoe/Jones Paper? When results differ markedly from other comparable studies, by a factor of 10 in this case, one should confirm if the figures quoted and calculations are correct, and not a source of error. Were the McIndoe/Jones figures correct? I believe they are not reliable. A review of all cases of CIS seen at NWH from 1955-1986 was undertaken by M. Jamieson and A. Macintosh, (senior cancer specialists at NWH) and accepted by the Cartwright Inquiry (Source: Dr G Collison, NWH, Auckland, NZ, A Position Paper, July 1988, referenced in Cartwright Report). This review found 1222 cases from 1955-1976 and 1815 from 1977-1986. Thirty-two patients were identified as having invasive genital tract disease following persistent CIS of cervix and eight of those patients had died of genital tract cancer by the end of 1986. Astonishingly, these results were simply ignored by the Inquiry...Yet they were not rejected as incorrect. The results do however give a very different set of statistics. In fact, only 32 cancers over 30 years in 3037 patients. This gives cancer rates of 1% which are comparable to other studies. For example, Kolstad4 treated 1121 women with CIN of whom 12 developed invasive cancer. (about 1%). Soutter,3 also noted that the groups containing a high proportion of women with CIN 3 had a higher rate of invasive recurrence, than those with lesser grades.. Jamieson and Macintosh, like McIndoe/Jones, were analysing data from women who had been diagnosed with CIN 3, as did Kolstad, but many other studies included all CIN cases, so one would expect better figures in those groups. In the 1960s and 70s there was a change in the management of CIN, and at NWH and other places there were heated debates as to how ‘conservative' one could be. Learning curves of clinical management involve positive and negative outcomes.In this case unnecessary hysterectomy vs invasive disease, as treatment changed from obligatory hysterctomy in the 1950s to the more conservative approach now used. I do not hold with the Cartwright conclusion that the doctors at NWH withheld treatments as an experiment, which as recently as 2009 was described in the NZ Health Research Council's Ethical Notes...as ‘similar to Nazi experiments', and which resulted in excessive cancers. I believe Dr Green was determined not to do unnecessary radical surgery. Dr McIndoe believed in more invasive treatment; both were doing their best to avoid women getting invasive cancer—and importantly both were driven by a desire to do the best for their patients. Dr Helen Overton Vejle Hospital Denmark