KEY POINTS:
Twenty years after the Cervical Cancer Inquiry into National Women's Hospital, gynaecologist Ron Jones, gazes out across the bay and smiles. "You don't expect apologies, that'd be asking too much," he says. "But this latest study confirms, without doubt, that women who had limited biopsy for diagnosis, without treatment, and continued to have abnormal [cervical] smears had a 50 to 100 times higher risk than those who had their cancer eliminated by treatment such as cone biopsy."
Far too much retorts Jones' former colleague and eminent obstetrician, Dr Graeme Overton, "this study is absolute, total rubbish!"
The research they are talking about is not entirely new. Indeed it is based on the most controversial research study ever in New Zealand - a study that pitted doctors against doctors, women against women and journalists against journalists. But this time the research has been carried out over 40 years, by some of the country's leading researchers, epidemiologists and pathologists. Results were published in the prestigious Lancet magazine to worldwide acclaim.
Indeed, points out Professor Jones, who is now chairman of the Scientific Committee of the International Federation of Colcoscopy and Cervical Pathology, it is part of the reason that this year's meeting of the Federation will be in New Zealand.
Overton, on the other hand, though 78 and retired for a decade, still disputes the findings.
The argument goes back to the 1960s when Professor Herbert Green of National Women's Hospital, undertook what became known as 'The Unfortunate Experiment' into cervical pre-cancer. Green studied hundreds of women who showed evidence of what doctors then called "carcinoma in situ" or CIS (pronounced kiss) which was widely suspected to be the precursor to cervical cancer. The conventional treatment was hysterectomy until the early '60s when fertility-preserving cone biopsy became the preferred method.
At the time, National Women's was famous for its research. William Liley startled the world by performing successful fetal blood transfusions on Rh negative women and in 1968, Professor Graham (Mont) Liggins had discovered the maturing effects of steroid therapy on lung development in premature babies. Both became internationally famous and were knighted.
The tall, imposing Herb Green of the big, raw-boned hands, was ambitious too.
He was part of a regime, headed by the legendary Dennis Bonham, that considered women had a duty to be used as "teaching material". Driven, he said, to help young women who had CIS but still hoped to have children, Green set out to prove that CIS was not a pre-malignant condition and did not go on to develop full-blown cervical or vaginal vault cancer.
Under his "1966 Proposal" which was endorsed by the hospital hierachy, Green took a hands-off approach. Women with abnormal cervical smears were diagnosed with punch biopsies and and sometimes colcoscopies for signs of their CIS progressing.
"The aim," said Green, "was to prove that CIS was not a pre-malignant disease." They were, however, carefully monitored with repeated smears. Many had multiple small punch or wedge biopsies to confirm CIS was still present.
Ron Jones, who had arrived at National Women's after a stint in England when Green's experiment was well under way, was worried by Green's approach. At 33 with a young family and the big job of supervising and helping the hospital's house surgeons deliver babies, Jones was also involved with Dr William (Bill) McIndoe, the colcoscopist who monitored Green's patients. He feared Green was "creating time bombs which would sooner or later go off".
He was right. Many untreated or inadequately treated women got invasive cancer. Several died.
By 1978, says Jones, the shy, self-effacing McIndoe, who had studied the cervixes of Green's patients for 20 years - and noted the changes - tried to have the trial stopped. For decades he had argued with Green about his precarious methods and the lack of definitive treatment offered to women who, he said, showed clear signs of impending cancer. It was, he said, too risky. Green took no notice. When an internal inquiry failed to address his concerns, he decided to go public.
With the help of Jones and pathologist Jock Mclean - he collated the results of Green's study in his McIndoe Paper of 1984 and, after signalling its findings at offshore conferences, published in the acclaimed Journal of the American College of O&G, Obstetrics and Gynaecology.
With 1000 cases dating from 1955-1976, it was the largest study, with the longest follow-up, of its type in the world. And its findings were dynamite, especially for a local profession still unconvinced that CIS was the precursor to cancer: Women who had persistent abnormal smears after being diagnosed with CIS were 25 times more likely to develop cancer than those with normal smears following adequate treatment.
But although it created widespread comment in America and Europe, McIndoe's paper was met with silence at home.
Three years later those same results, written up by feminists Sandra Coney and Phillida Bunkle interwoven with the harrowing case study of one of Green's patients known only as "Claire" were published in the popular monthly, Metro magazine.
Suddenly Green's study became the biggest medical scandal of the century. "Claire's" suffering at the hands of Green and his team made harrowing reading, while Coney's figures reported that an untreated group of women with CIS died at excessive rates.
An inquiry was ordered within weeks. And a year later, after the eight-month Cartwright investigation, Green and Bonham were charged with disgraceful conduct by the Medical Council though Bonham's were later dropped "because of ill health".
What was the real reason? Says Jones, the medical hierarchy, headed by Bonham and National Women's consultants, moved to protect Green and his study.
Four years later there was a second article in Metro magazine, this time dismissing the first story as a feminist-driven witch hunt against the medical fraternity and casting doubt on the methods used to vilify Green's experiment.
The doctor who spoke up for Green in Metro, declaring the Cartwright Inquiry was "a scam", was Graeme Overton, who worked at both St Helen's and National Women's Hospitals and was the private specialist that "Claire" went to after she became disillusioned with Green's treatment.
Weeks later the Auckland Division of Specialists in Obstetrics and Gynaecology circled the wagons, declaring "unanimous support for Dr Graeme Overton's interpretation of the 1984 McIndoe paper.
Today, more than 40 years after Green's experiment began, the controversy rages on. Ron Jones, now 67, is a specialist in pre-cancer "diagnosis and management of women with problems that may turn to cancer".
Green and Bonham are dead. McIndoe died two years after delivering his 1984 paper, possibly from stress. Sandra Coney, meanwhile, is still a feminist activist and has branched out into fighting for the environment, Phillida Bunkle is a discredited Alliance MP accused of shoplifting.
And Graeme Overton, now retired, is still fighting to have the names of his old colleagues families' cleared for all time. As he sees it, the "Unfortunate Experiment" got it wrong and was a catalyst for dismembering New Zealand's once-first class obstetric and gynaecological service.
"Over the past 20 years, control of health has been removed from the medical profession," he wrote in March. "The revelation published in Metro by a feminist activist group [led to] the medical profession being disgraced and could no longer be trusted. The recommendations of a subsequent inquiry resulted in a paradigm shift in all facets of New Zealand medical services."
Not so, says Jones. "Overton and his colleagues failed to grasp that, while many of Green's patients were eventually treated, their treatment was totally inadequate, the disease persisted and the women remained at risk of cancer."
Jones has surely proved his point. With his associate from 1984 days, David Skegg, backed by a team of experts, including Katrina Sharples, Charlotte Paul, Margaret McCredie, Judith Baranyai and Gabriele Medley, he has published the research that should settle the argument for all time: CIS (now called CIN3 or cervical intrepithelial neo plasia) is a precursor for cancer.
Armed with $250,000 from the Cancer Society, the epidemiologists, pathologists, doctors and nurses went through all old patient records extracting data: age, race, parity and particularly their follow-up details. "Did they get cancer during follow-up?" Biopsies and cytology slides were rigorously re-examined using sophisticated new techniques. Patients were traced through the cancer register and death registries here and in Australia.
As Jones explains, "patients were followed as long as 45 years - the median was nearly 30 years - and we put together a mountain of data".
The new research shows that a subset of 92 women, managed only by punch or wedge biopsy, had a 50 per cent risk of cancer if they continued to have smear abnormalities. By contrast, only 0.7 per cent of the 593 women with adequate treatment (mainly cone biopsy or hysterectomy) had developed cancer after 30 years.
So why, after all these years, is Jones still waiting for an apology from his old colleagues at the Auckland branch of Specialists in Obstetrics and Gynaecology and National Women's Hospital? Why the deafening silence? "Misguided loyalty to old friends and colleagues," he says. "It wasn't just the College, it was every doctor. There was also a horror of feminism and a disdain among my colleagues for letting the popular media dictate medical misadventure. They banded together to protect the old order - even though Bonham later admitted Green's conservatism was so strong he 'showed a touch of fanaticism,' he still protected him."
Says Dr Overton, "I'm not pitting blame but I do have strong feelings for the families who've been disgraced. There never was an untreated group of patients at National Women's Hospital." In fact, he says, failing to register that Green's study was never concerned with invasive cancer, "National Women's study produced the best mortality figures for cervical cancer in the world!"
Counters Jones, "no matter how the information is disseminated, the fact remains that Green got it wrong. "He under-treated and played with the lives of hundreds of New Zealand women. And all this took place while McIndoe was pointing out the problems.
"McIndoe is the hero of this story. And he was ignored."
