' of the American Cancer Society. The program nowincludes: a. A review of systems and a complete medical examination. b. Advice on decreasingrisk factors and on self-detection of lesions. c. Pelvic examinations with Papanicolaou smears. d. Stool testing for occult blood. e. Amammographyunit and a flexible 65cm sigmoidoscope have been recently acquired. 2. Pursuant to the intent of PL 95-134, the examinations and procedures listed under (1) are performed more frequently than proposed by the American CancerSociety for populations not at increased risk for cancer. Therefore, the physical examinations are annual and include a pelvic examination and Pap smearfor all exposed women. Annual mammograms, using a new low-dose mammographyunit, will begin at age 35. Routine mammography was not begunearlier because older machines produced dosesof x rays which were judged unacceptable for routine annual screening of a population already at increased risk for radiogenic breast cancer. Rectal examinations and stool testing for occult blood are done annually, starting at least by age 40. Routine flexible sigmoidoscopy malities are actively sought. To this end, the medical program provides the following: a. Annual thyroid examinations by an endocrinologist or surgeon. b. Thyroid function testing for all exposed persons, annually for the people of Rongelap and biennially for those of Utirik. c. Thyroid suppression (Synthroid) for all the Rongelap exposed. The intent is to decrease the likelihood of thyroid malig- nancy. d. Serum prolactin levels on all exposed persons every three years. The most commonly encountered pituitary tumorin the United States is the prolactinoma. e. Annual complete blood counts, including a platelet count. f. Evaluation for “paraneoplastic” evi- dence of neoplasia, such as monoclonal spikes on serum protein electrophoresis (myeloma, lymphoma) and abnormal serum calcium levels (parathyroid adenoma, hypoparathyroidism, metastatic tumor). gram suggest previously undocumented late effects of radiation exposure in man. These include an increased incidence of pituitary neoplasms anda trend toward lower blood cell counts (Adams et al. 1984a, 1984b). Another late effect, hypothyroidism, was documented in 4, There is ongoing evaluation for clinical evidence of depression in immunocompetence. The more recent medical surveys of serum immunoglobulins, toxoplasma antibodies, serologic markers of hepatitis B, and tuberculin sensitivity reveal no good evidence that the exposed Marshallese have a significant impairment of their immune mechanisms (Adams et al. 1984b). However, the matter shouldnot be considered settled, and continued surveillance for evidence of increased risk for unusual manifestations of infectious disease is a part of the medical program. 5. The treatment of any neoplastic process which could conceivably be radiation related is donein referral facilities, generally in Honolulu, Hawaii. The exceptionsare thyroid nodule surgery, which continuesto be performedby Dr. Brown Dobyns, Professor of Surgery at Case Western Reserve University, and therapy for pituitary neoplasia, which has been doneat the National Institutes of Health, Bethesda, Maryland. Few such lesions can be adequately treated in the health facilities of the Republic of years of the program (Larson et al. 1982). Therefore, nonmalignant endocrine neoplasms, endocrine dysfunction, and hematologic abnor- also refers almost all diagnostic workups for malignancy to Honolulu. For example, if the causeof persistent occult bloodin the stool is not will be offered before age 50 and will be repeated every otheryear, or more frequently if clinically indicated. ° 3. The delayed effects of radiation exposure are generally considered to be limited to malignant disease. The exposed Marshallese, however, receive additional attention for two reasons. First, their radiation exposure was ofa unique type, and atabulation of risks derived from the statistics of other irradiated populations may not cover the range of late consequences that could befall them. Second, data now collected by the Brookhaven medical pro- + Cz? 77y ec ect 4 CHi some of the exposed Rongelap during earlier the Marshall Islands. The medical program