Cancer is a Pacific Concern
The islands of the US Affiliated Pacific Islands (USAPI) are scattered across the immense Pacific Ocean north and south of the equator spanning one million square miles and five time zones that include the international dateline. Each of the USAPI jurisdictions and territories is rich in culture, history and language, but small in population. The islands are fragile and diverse but have a long past offering plentiful, sustainable eco-systems that supported their indigenous populations.
While the economic, health and political environment of the ten USAPI jurisdiction and territories are related, each island nation has its own unique strengths as well as challenges. The current health infrastructure in the USAPI suffers from severe resource limitations. Health status indicators demonstrate significant disparities for almost all non-communicable diseases, including most cancers. Factors influencing policy issues, political relationships, the economy, the environment, diverse cultures, stressed health systems, education, limited human resource development and the sheer physical isolation of these islands all contribute to the enormous challenges in achieving health equity in the USAPI.
One of the most dramatic illustrations of the severe resource limitations in the USAPI that contribute to health disparities is the per capita total health expenditure. Significant variations occur even between the ten jurisdictions. When compared to the United States the difference is enormous. See Figure 1 below based on 2006 data from the World Health Organization.
Figure 1: USAPI per capita health expenditure
Colonization and rapid westernization have adversely affected many of the social, cultural, and environmental structures and practices that traditionally supported and protected the health of the islands, their waters and their people. Within only the last two decades the epidemiologic profile in the Pacific has shifted dramatically from predominantly infectious diseases to among the highest incidence and prevalence of preventable chronic diseases in the world, such as diabetes (47.3% in American Samoa) and hypertension, cardio-vascular disease (34% in American Samoa and 21% in the Pohnpei).
Cancer mortality is now the second most common cause of death in nearly all USAPI jurisdictions. Multiple factors contribute to and explain the high cancer mortality:
Figure 2: Multiple factors contribute to high cancer morbidity & mortality in the Pacific
- Lung and oral cancer prevalence is high in all countries attributable to tobacco and combined tobacco-betel nut misuse.
- Preventable and curable cancers such as cervical and breast cancers occur at a younger age, demonstrate high incidence rates comparable to other developing countries and result in high mortality due to lack of primary prevention and early detection.
- The availability of supplies or funds to ship and process screening tests varies widely.
- Mammogram is not available in many places in the Marshall Islands nor in the Federated States of Micronesia.
- A working colposcope for diagnosis and early treatment of cervical cancer is non-existent in several areas of the Freely Associated States
- The availability of fecal occult blood testing, colonoscopy or prostate-specific antigen varies and is not available on some jurisdictions.
- High rates of thyroid cancers and nodules in the RMI i,ii attributable to the U.S. Nuclear Weapons testing program in the 1950s.
- A pathologist or radiologist is not present in several of the jurisdictions.
- Most of the USAPI jurisdictions do not have an oncologist.
- No radiation oncology is available in the region, most cannot do maintenance chemotherapy.
- Medications for palliative care, such as pain are often in short supply or not available.
- Health personnel are inadequately trained and shortages persist.
- Local support groups or patient navigators are only recent, overcoming cultural tradition, beliefs and practices to share their personal stories for the first time.
- The concept of hospice care is relatively new, however, home care for loved ones with cancer or chronic illness is the Pacific Islands way.
i Palafox NA, Katz A., Johnson D., Minami J., Briand K. Site-specific Cancer incidence in the Republic of the Marshall Islands. Cancer 83:1821-4.
ii Palafox, NA, Minami J. Cancer in the U.S. Associated Pacific countries: Cultural Considerations. Asian American and Pacific Islander Journal of Health Vol. 6 No. 2:401-404.
Reducing Cancer Disparities in the Pacific
Regional Partners and Collective Action
The Pacific Region Cancer Coalition, under the leadership of the Cancer Council of the Pacific Islands (CCPI), developed the Pacific Regional Comprehensive Cancer Control (RCCC) Plan. The Regional Plan is harmonious with the individual USAPI CCC plans. Together the regional and USAPI CCC plans commit to addressing the collective challenges and mobilizing cohesive action in the Pacific region. The individual 5-year USAPI Comprehensive Cancer Control plans are available on this website under the “Pacific Partners” tab.
The Pacific Regional Comprehensive Cancer Control Plan strives to maintain a U.S. Affiliated Pacific regional platform for discussing, addressing and reducing cancer. The PRCCC is a long-term plan, working in conjunction with the Pacific Islands Health Officers Association (PIHOA) regional initiatives such as regional laboratory services, human resources for health and quality assurance. PIHOA is the paramount health sector leadership in the region representing the Ministerial offices of every Ministry or Department of Health. The Plan aims to develop minimum standards for cancer prevention and care for the USAPI largely through education, advocacy and policy development and by providing technical leadership and guidance for the implementation of the jurisdiction-specific CCC plans. For example, RCCC develops regional policies regarding the utilization of cancer data, provides access to regional expertise in cancer prevention, early detection and care, provides regional technical support for all components of the comprehensive cancer plan, and promotes regional cancer advocacy at the U.S. national level.
In addition, the Pacific Regional Central Cancer Registry has been established under the Centers for Disease Control and Prevention, National Program of Cancer Registries and every USAPI jurisdiction now maintains a cancer registry managed by a full-time registrar. The Pacific Center of Excellence in the Elimination of Disparities (CEED) focused on breast and cervical cancer was also awarded to the Department of Family Medicine and Community Health, John A. Burns School of Medicine, University of Hawaii. Funded by REACH US at CDC, Pacific CEED is a regional program that adds value to the Regional CCC Plan and the ten USAPI CCC Plans through technical assistance, short-term grants and human resources development using community-based approaches and the socio-ecological model.
Regional Goals and Objectives
The strategies outlined in the Pacific Regional Comprehensive Cancer Control (RCCC) plan are comparatively short-term (2-10 years) and focus on regional efforts in training and planning for policy-making and health systems strengthening to impact primary prevention, early detection, diagnosis, treatment and data quality. Each individual USAPI jurisdiction also has a 5-year Comprehensive Cancer Control Plan. Each USAPI-CCC plan contains prevention, early detection, diagnosis & treatment, palliative care and quality of life objectives and strategies that are community-based and tailored to their particular situation and environment. The priority objectives include:
Figure 3: RCCC Priority Objectives
- To strengthen and expand regional collaboration, planning and advocacy affecting all components of comprehensive cancer prevention and control
- To diagnose cancer in individuals as early as technically possible within the USAPI region
- To improve the capacity to treat cancer effectively within the USAPI region
- To collect, analyze and report accurate cancer-related data across the region