Most cancer cases can be well managed on Guam.

There are several inaccuracies in an otherwise reasonable article:

1) Guam today is as competent as any center, and more than many, to diagnose cancer. We have skilled radiologists who can obtain tissue from almost any site with a small needle, and skilled pathology with backup from Hawaii on difficult cases.


2) Chemotherapy and radiotherapy in the hands of some skilled professionals on Guam are able to match any U.S. center with the exception of some very highly specialized procedures very occasionally necessary.

3) Most surgeons on Guam can handle the simple cancer surgery quite well, but patients with extensive or complex surgery, due to lack of equipment or skills on Guam, are best treated off island at specialized centers.

4) Specialized centers, with the exception of some surgical procedures, means the U.S., and not Manila! The overall medical care in Manila is far below Western standards, including Guam. I refer to faulty knowledge or performance, particularly in the cancer field. In 14 years, I have yet to see a patient with breast cancer return from Manila with her breast attached, whereas simple lumpectomy with sparing of the breast is appropriate in more than 85 percent of cases and has been practiced universally – except in the Philippines – for the past 20-plus years, and is the medically preferred treatment with better survival than mastectomy. Then there are inappropriate pathology reviews and lack of sophisticated special tests to decide therapy, as well as an inappropriate choice of therapy. By the time the patient is seen here, it is often too late to institute proper therapy if this has not been started. Patients return with scant or no records, and proper ones are almost impossible to obtain or interpret.

5) Contrary to statements made by insurance interests, patients are indeed herded toward Manila. There are policies that restrict off-island care to Manila, and patients often are exempt from paying their co-pay on other policies if they choose Manila. This is with few exceptions done for cost containment rather than for "better care." Ironically, the newer advanced drugs, if even available in Manila, are no cheaper than on Guam, with only the service being cheaper.

6) For off-island referral, the decision on this should be at the discretion of the treating oncologist, to decide if this is necessary. It should not be made by insurance interests, friends, family or other physicians ignorant of the cancer field. Except for some surgeries in Manila, this should automatically mean the U.S.!


7) To answer the statement of no coordinated approach to patients, there is indeed such an approach, but not Guam Regional Medical City. That includes pathologists, radiologists, medical and radiation oncologists working as a cohesive group that would rival the best care given anywhere in the states.

8) As everyone should know, the high rate of cancer on Guam is to a large extent self-induced by: 1) tobacco use, especially cigarettes; 2) betel nut ingestion, especially with tobacco; 3) excess alcohol consumption; 4) obesity; 5) avoidance of simple screening procedures like Pap smears, colonoscopy or other screening methods and HCV testing if any use of drug shooting had been used anytime in the past. These are the known factors responsible for the majority of cancer on Guam. There's no need to look for 60-year-old nuclear tests or other toxins.

9) While no one would argue with the universal axiom that there is much improvement to be made in cancer care – the ridiculous price of drugs being one such case – overall, most cancer cases can be well managed on Guam with very occasional need for referral for complex cases better handled in highly specialized centers. Overall, there is no place like home.


Dr. Samuel Friedman is an oncologist practicing on Guam


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