The editor has allowed Professor Bryder to reopen correspondence relating to her book A History of the ‘unfortunate experiment’ at National Women’s Hospital on the mistaken basis of “important new information”. Reluctantly, I must respond.1

Bryder’s reasoning that the authors of a recent “systematic review and meta-analysis of the clinical course of untreated cervical intraepithelial neoplasia (CIN) 2 under active surveillance”… “support what Associate Professor Herbert Green suggested to the NWH Hospital Committee in 1966” is incorrect.2 Whereas the meta-analysis was restricted to the study of CIN 2 mainly in women under 30 years, mainly for a few months, and with treatment either if CIN 2 persisted or if CIN 3 was diagnosed; Green, on the other hand, studied women who had CIN 3 (some for almost 20 years) or microinvasive cancer at the outset, he ignored age limitations and safeguards, aimed to follow women indefinitely and (clinically) invasive cancer was the endpoint at which treatment was given.3,4

Green was familiar with inter and intraobserver variation:5,6 indeed, when some of his patients with histologically diagnosed CIN 3 later developed cancer he personally reviewed the original histology himself and determined the woman had invasive cancer at the outset and removed the case from his study.7 At no time has HPV status been taken into account when managing CIN 3.

Bryder headed her letter Primum non nocere. Presumably Green intended to do no harm at the outset, but sadly he did great harm. As spelt out in the new paper she cites when women with CIN 2 were subject to active surveillance for up to five years, and treated if their disease progressed to CIN 3, only 0.5% developed invasive cancer.2 By contrast the authors of the systematic review cite the re-examination of Green’s study by McCredie et al of the women with CIN 3 followed without treatment for five years, of whom 17% developed invasive cancer.8 This is 34 times higher. Why has Professor Bryder persistently refused to answer my question: why did so many women in Green’s study develop cancer?9,10 Until she answers this question her defence of Green is spurious.

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The editor has allowed Professor Bryder to reopen correspondence relating to her book A History of the ‘unfortunate experiment’ at National Women’s Hospital on the mistaken basis of “important new information”. Reluctantly, I must respond.1

Bryder’s reasoning that the authors of a recent “systematic review and meta-analysis of the clinical course of untreated cervical intraepithelial neoplasia (CIN) 2 under active surveillance”… “support what Associate Professor Herbert Green suggested to the NWH Hospital Committee in 1966” is incorrect.2 Whereas the meta-analysis was restricted to the study of CIN 2 mainly in women under 30 years, mainly for a few months, and with treatment either if CIN 2 persisted or if CIN 3 was diagnosed; Green, on the other hand, studied women who had CIN 3 (some for almost 20 years) or microinvasive cancer at the outset, he ignored age limitations and safeguards, aimed to follow women indefinitely and (clinically) invasive cancer was the endpoint at which treatment was given.3,4

Green was familiar with inter and intraobserver variation:5,6 indeed, when some of his patients with histologically diagnosed CIN 3 later developed cancer he personally reviewed the original histology himself and determined the woman had invasive cancer at the outset and removed the case from his study.7 At no time has HPV status been taken into account when managing CIN 3.

Bryder headed her letter Primum non nocere. Presumably Green intended to do no harm at the outset, but sadly he did great harm. As spelt out in the new paper she cites when women with CIN 2 were subject to active surveillance for up to five years, and treated if their disease progressed to CIN 3, only 0.5% developed invasive cancer.2 By contrast the authors of the systematic review cite the re-examination of Green’s study by McCredie et al of the women with CIN 3 followed without treatment for five years, of whom 17% developed invasive cancer.8 This is 34 times higher. Why has Professor Bryder persistently refused to answer my question: why did so many women in Green’s study develop cancer?9,10 Until she answers this question her defence of Green is spurious.

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