The Cartwright Inquiry was a committee of inquiry held in New Zealand from 1987 to 1988 that was commissioned by the Minister of Health, Michael Bassett, to investigate whether, as alleged in an article in Metro magazine, there had been a failure to treat patients adequately with cervical carcinoma in situ (CIS) at National Women’s Hospital (NWH) by Herbert Green, a specialist obstetrician and gynaecologist and associate professor at the Postgraduate School of Obstetrics and Gynaecology, University of Auckland.
Coney and Bunkle took the title of their article from a 1986 letter in the New Zealand Medical Journal by Professor David Skegg, a University of Otago cancer epidemiologist and expert in population screening in which he referred to "the unfortunate experiment at National Women's Hospital" in his reply to Green about the study.
Green's proposal stated that all patients with a diagnosis of CIS under the age of 35, with positive smears and no colposcopic evidence of invasive cancer and without a ring or cone biopsy, would be followed.
[6][7][8][9] In 1969, he wrote about his methods more clearly than in his proposal: "In 1965 [sic] the SMS of NWH initiated a project under the supervision of the author, for patients up to 35 years of age whose only abnormal finding was positive cervical cytology.... a histological diagnosis was to be established by punch biopsy of the most colposcopically significant area.
[6] In 1970, Green published further results and described his study: "The only way to settle finally the problem of what happens to in situ cancer is to follow indefinitely patients with diagnosed but untreated lesions.
[7] In the last paper, in 1974, Green again described his study: "This series of 750 cases of in situ cervical cancer, and the following of 96 of them with positive cytology for at least two years, represents the nearest approach yet to the classical method of deciding such an issue as the change of one disease state to another – the randomised controlled trial.
A later and separate re-evaluation of the invasive potential of CIS, based on a review of NWH patients' files, was published by McIndoe et al, with very different findings.
[2] District Court Judge Silvia Cartwright was appointed by warrant dated 10 June 1987 as a Committee of Inquiry to inquire into the treatment of cervical cancer at the National Women's Hospital and other matters.
Evidence was heard from 59 witnesses, including from medical experts brought from around New Zealand, as well as from Australia, United States, Japan, UK, and Norway.
In respect of Term of Reference One (TR1), the Report defined ‘adequate treatment’ of CIS since the 1950s as being that based on generally accepted treatment [at NWH this was cone biopsy][11] together with evidence of eradication of the disease, and concluded that, by that standard, there had been a failure to adequately treat a number of women with CIS at NWH, For a minority of women, their management resulted in persisting disease, the development of invasive cancer, and in some cases, death.
"The inference to be drawn from Dr Green’s proposal and published papers is that CIS will progress to invasive cancer in only a very small proportion of cases if at all.
[15] The International Federation of Gynecology and Obstetrics published statistics from the late 1970s which showed that the hospital ranked among the best institutions in the world in regard to five-year survival rates for patients with carcinoma of the cervix.
Judge Cartwright heard evidence, also, of disrespectful teaching practices, such as the insertion and removal of intrauterine devices on patients under general anaesthetic for other purposes, and vaginal examinations performed by undergraduates on anaesthetised women, in both cases without their prior knowledge or consent.
[19] Recommendations in the Report of the Cervical Cancer Inquiry 1988[10] contributed to sweeping changes in law and practice around health and disability services’ consumers' rights in the 1990s and beyond.
The Cartwright Report recommended setting in place a system of regional ethics committees, focused on the protection of patients, independent of hospitals, of which half the members would be lay people.
[22] Valerie Smith, a friend of Green’s, and his colleague, Dr Bruce Faris filed judicial review proceedings in the High Court, seeking to challenge Judge Cartwright’s findings in the Report.
[23] Eventually 19 women who took legal action received compensation in an out-of-court settlement which stated that no fault or liability was admitted by the doctors or the institutions involved.
[31][32][33][34] Complaints to the University of Auckland about Bryder’s interpretation can be found here:[35] http://www.cartwrightinquiry.com/?page_id=92 By contrast to these criticisms, historian of medicine Ilana Lowy who has written extensively on the history of cancer, including cervical cancer, in Britain and Europe, in a review in the book, wrote of Bryder’s ‘careful display of the complexities of the management of uncertainty in treatment of cervical malignancies’,[36] and Cambridge Professor Emeritus of Haemotology Robin Carrell praised the book as ‘an outstanding example of the beneficial function of the medical historian.’[37] Similarly, Raffle et al support Green’s practices in a new look at the Cartwright Inquiry itself (chapter 8).
This was at a time when there was ample scientific reason for concern about the damage caused by hysterectomy or cone biopsy and uncertainty about whether immediate use of these procedures was automatically the best thing to do for symptomless lesions, particularly in young women who might want children.
Green's practice, although motivated by a desire to avoid unnecessary and damaging interventions in symptomless women, was easy for others to condemn due to the lack of any relevant policy, research, or ethical framework for cervical screening at that time.'
In a paper in the Journal of Clinical Epidemiology in 2020[30] Iain Chalmers, champion of evidence-based medicine and co-founder of the international Cochrane organisation noted that "the Cartwright Inquiry provides no trustworthy evidence of harm from the adoption of the conservative management introduced by Green" "it is now clear that the treatment and monitoring methods introduced by Herb Green have benefited numerous women through avoidance of major surgery and preservation of fertility."
Dr Ron Jones, whistle blower and an author of the 1984 McIndoe et al paper, published an insider’s account in 2017, having been on the staff of NWH as an obstetrician and gynaecologist from 1973.
The authors concluded that "during the ‘clinical study’ (1965–1974), women underwent numerous interventions that were aimed to observe rather than treat their condition, and their risk of cancer was substantially increased".
[47] The authors concluded that "Women with microinvasive carcinoma were included in a natural history study of CIN3; they underwent numerous procedures designed to observe rather than treat their condition, and had a substantial risk of invasive cancer.