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February 4th is World Cancer Day, and we wanted to highlight the cancer work being done at JABSOM in our Pacific Cancer Programs. We talked with the group about the strides they’re making in the USAPI when it comes to battling this disease.
*Answers provided by Dr. Neal Palafox.
What do the cancer rates look like in the USAPI?
*source: Pacific Regional Central Cancer Registry (PRCCR), 2007-2023, unpublished
Our latest biennial Cancer in the U.S. Pacific 2007-2022 report, which provides more granular details about the cancer burden the U.S. Pacific Islands face, can be accessed via our website (pacificcancer.org) or using the following direct address.
While certain cancer rates in the region are below the U.S. national average, the USAPI faces a severe shortage of resources and infrastructure to address these cancers. The high prevalence of cancer in the USAPI is particularly tragic given that the local health care systems lack the critical support structures, such as no mammography in most of the Federated States of Micronesia, and treatment options, such as chemotherapy, are unavailable in most of the USAPI. Many of the cancers displayed in the table above are preventable. Because of the low healthcare resource capacity for cancer in the USAPI and since cancer is preventable, the cancer rates take on a different level of seriousness than in a U.S. setting. This underscores the importance of early intervention and preventive care, which can detect these cancers at an early stage, thereby increasing survival rates and reducing the financial burden on individuals, their families, and the island's healthcare system.
How, if at all, does it differ from the United States?
Generally speaking, breast cancer is the most frequently diagnosed cancer type in both the U.S. and the U.S. Pacific, when comparing 2018-2022 cancer datasets using the Pacific Regional Central Cancer Registry (PRCCR) and the Centers for Disease Control and Prevention (CDC) data tools.
In contrast, cervical cancer presents a major health disparity, with Pacific island rates being more than double those of the U.S., with some regions, like the Republic of the Marshall Islands, experiencing a particularly extreme burden, with cervical cancer rates that are among the highest in the world and far exceed U.S. levels.
Liver cancer is another area where the Pacific burden generally exceeds that of the U.S. For example, liver cancer rates in the Republic of Palau are at least twice as high as the U.S. national average. This is primarily driven by the high obesity and Hepatitis B rates.
Oral cavity and pharyngeal cancer rates are significantly higher in certain jurisdictions like Yap and Pohnpei States, Federated States of Micronesia, and the Commonwealth of the Northern Mariana Islands, compared to U.S. averages. In fact, Yap State has some of the highest oral cancer rates in the world, surpassing the U.S. average due to regional habits like betel nut chewing.
Lung and bronchus cancer is the second most common cancer in the Pacific, though its incidence rate remains lower than the U.S. continent average.
Prostate cancer ranks third in the Pacific islands, yet its rate is notably lower than the rate observed in the U.S., which could be due to many factors, like the lack of widespread, easily accessible screening options for the Pacific population.
While colon and rectum cancers are among the top four concerns in both geographical areas, the Pacific sees a lower rate of these cases compared to the U.S.
Uterine cancer is a top-five priority in the Pacific islands and likewise remains a major cancer type for women on the U.S. continent. The incidence rate of uterine cancer in American Samoa is higher than in the U.S.
Ultimately, these comparisons demonstrate that while some common U.S. cancers are less frequent in the Pacific, others like cervical and liver cancer represent much more severe regional health threats. It must be stated that these numbers do not relay a clear message on the actual, very severe burden these cancer numbers place on the island jurisdictions.
Considering the rural and remote location of the USAPI, how is cancer outreach, screenings, and treatment done there?
The USAPI comprises three U.S. Territories (Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands) and three sovereign nations under Compacts of Free Association (the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau). The 415,000 residents are spread across hundreds of islands spanning over one million square miles and five time zones.
Education & Prevention: Health care providers and community health workers often travel to remote villages and outer islands to provide education. Because digital access can be spotty, face-to-face outreach and radio broadcasts remain the standard for increasing cancer awareness.
Screening: While most cancer screenings and biopsies are centralized at hospitals on the main island, breast and cervical cancer screening are accessible on remote islands. By deploying healthcare workers trained in visual inspection with acetic acid (VIA) and clinical breast exams to remote areas, the health system ensures residents can access early-detection services without requiring long-distance travel.
Treatment: Due to the absence of local oncology infrastructure in the Pacific islands, patients are referred for cancer treatment off-island to Hawaii, the continental U.S., and internationally. Many patients from the region often seek care in the Philippines and Taiwan for more affordable care, or those with financial resources may opt for treatment in Hawaii or the continental U.S.
Remote locations are much harder to access, and more traditional education and outreach efforts are even more challenging. Translation into many languages is challenging, and deploying modern technologies across the region is difficult. At-home and self-collected HPV screening has shown to be important in USAPI jurisdictions.
Training more healthcare professionals is important so they can implement modern health technologies in island settings and meet treatment needs. Treatment must be scaled up to all USAPI jurisdictions.
How does JABSOM’s Pacific Cancer Programs make access to care and screenings easier?
The Pacific Cancer Programs provide public health and medical education, capacity building, and workforce development through technical assistance to local health programs and by implementing public health interventions in cancer prevention and screening. We’ve introduced the latest screening technologies for rural areas, such as self-collected HPV tests, while maintaining some of the tried-and-true, resource-appropriate methods, including visual inspection with acetic acid (VIA), in the Pacific islands. With limited healthcare resources in the USAPI, telehealth sessions strengthen the local health system and increase workforce capacity to improve cancer care by providing cancer-related education and case management opportunities for local healthcare providers.
Medical professionals receiving education at JABSOM should be aware of what technologies are available in the US Pacific and what can be replaced by more modern/advanced technologies, and which should be kept due to the fact that they ‘just work’ and are appropriate to an island setting. It would also be important to understand how modern technologies and medical breakthroughs can be translated to the US Pacific and to identify the requirements for any such implementation.
What strides have you seen since the inception of the Pacific Cancer Programs?
Comprehensive Cancer Control Coordinators and Cancer Coalitions are having a better understanding of the cancer care continuum.
There has been a noticeable shift toward a proactive screening and prevention model, rather than focusing solely on ‘treatment’ and spot solutions.
Though cancer rates seem to be increasing, we feel (sadly, we don’t possess the data to prove this hypothesis) that it is due to the fact that, as outreach and screening become more available to the Pacific population, more cases are diagnosed within the USAPI population.
We see that decision-makers recognize the value of high-quality data to support decision-making, and that the use of limited resources is becoming more targeted.
Given the shared goals of the Cancer Council of the Pacific Islands (CCPI), we’ve seen an increase in activities focused on understanding the needs of cancer survivors and on meeting these needs with culturally appropriate local resources (such as pain management using non-medical tools, like art therapy).
More high-quality cancer case data is available through the central and island cancer registries that meet the CDC’s National Program of Cancer Registries standards, and we have seen an increase in customized cancer data fields to collect data relevant to island healthcare and public health decision-makers.
We have seen Pacific Islanders speaking with increasing ‘one voice’. Due to coordinated collaboration and a regional vision, we have seen more grant funding being awarded. We have seen regional partners, such as the UH Cancer Center, become more involved in research. Due to the success of such collaborations, we observed a gradual shift toward collaboration and resource sharing, as well as collaborative troubleshooting and solution-finding.
Collaboration with the Pacific Island Health Officers Association (PIHOA) has helped all US Pacific Islands translate data into actionable policy, a trend we hope will continue.
I remember from previous interviews with Dr. Palafox that the Pacific Cancer Program teams make it a priority to get the community’s input, so as not to make it seem like the team is just coming in with a ‘we know best attitude.’ How has that strategy paid dividends in the strides you’ve made?
The programs have been intentional in working with the local community coalitions and project stakeholders. Since 2004, the programs have sustained the Cancer Council of the Pacific Islands (CCPI), which is the regional cancer coalition steering committee comprised of one clinical and one public health representative from American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), the Federated States of Micronesia (Chuuk, Kosrae, Pohnpei, and Yap), Guam, the Republic of Palau, and the Republic of the Marshall Islands (RMI). The CCPI has remained operational to provide overall direction for the Regional Comprehensive Cancer Control (CCC) efforts.
Our approach is guided by the community’s priorities. The community knows the answers. We honor their expertise and lived experiences and partner with them to provide the tools and support needed to address the issues they identify.
The main dividends we’ve seen are the extent to which elements of the cancer care continuum (such as screening methods) were implemented in a culturally appropriate manner across jurisdictions, and how Pacific Islanders felt they were ‘theirs’ afterward. Not to mention sharing best practices and lessons learned as a group, which can significantly support the implementation phase of any public health project.
How do the people of the USAPI continue to help develop the strategies around cancer prevention and treatment?
The people of the USAPI continue to help develop cancer prevention and treatment strategies through strong community leadership and collaboration. Health coalitions exist in most USAPI jurisdictions, with objectives that align closely with local public health programs and healthcare systems. In addition, the Pacific Cancer Programs have provided shared funding to support policy, systems, and environmental (PSE) initiatives across the jurisdictions. PSEs are designed to promote healthy behaviors by making healthy choices easily accessible in the community.
These efforts go beyond individual education and awareness by addressing broader cultural, environmental, and systemic factors that influence health. By working at these higher levels, communities can create more sustainable and lasting impact. For example, establishing tobacco-free zones in public settings and developing feasible cancer guidelines and activities that leverage existing infrastructure and resources within the Pacific's resource constraints. For over 13 years, these preventive measures have strengthened local capacity, increased understanding of PSE approaches, and encouraged communities to partner with governments, non-governmental organizations (NGOs), and other entities to contribute in meaningful and effective ways.
What more needs to be done in the USAPI?
While the policy, systems, and environmental (PSE) approaches have been shown to influence more than individual behavior by shaping the settings in which people live, work, learn, and play, much more remains to be done in the U.S. Affiliated Pacific Islands (USAPI). Continued efforts are needed to expand and strengthen PSE initiatives across larger systems, including schools, healthcare, government, the private sector, workplaces, and large-scale community events, to reach more people and create a deeper, population-level impact.
Although projects have been initiated in multiple settings across jurisdictions, sustained, coordinated efforts are essential to reinforce and build on progress over time. Ongoing implementation helps normalize healthier practices and environments, ultimately creating healthy places with healthy people and fostering lifestyles and cultures of quality-living that can be sustained for generations.
Maintaining support for the medical record and vital-statics system and data collection framework is increasingly important, especially now that there is sufficient cancer data to show the impact of the public health program’s activities/results. It would be very advantageous for the U.S. Pacific if appropriate, EHR systems could be deployed throughout the region that can share and sync data with each other. Laboratory services and resources could be strengthened to further support screening and early detection priorities. If a cancer case can be diagnosed in its early stages, there is a very high chance that it can be treated locally, without having to arrange treatment services for cancer survivors who are referred off island, like Hawaii.
There needs to be more support for programs similar to the ongoing regional public health and healthcare programs, and additional venues should be opened for data synchronization, sharing, and joint analytics.
How can JABSOM or the state of Hawaiʻi help?
JABSOM can support through its residency program, ensuring that medical students learn basic cultural competency skills and understand the dynamics of healthcare and cancer care in a pacific island setting. As the state that serves many Pacific Islander communities and individuals who came to Hawai`i to access care and resources not locally available to them, it is important for JABSOM students to understand the cancer continuum, the latest treatments, and how to translate that knowledge to this cultural setting and for people from these communities. For example, it would be great to have more MD5 students who can be exposed to the culture, geography, and unique settings, and experience healthcare at the local island hospitals. JABSOM must train the workforce to understand the dynamics and translate the latest screening and treatment guidelines for low-resource settings, using a culturally accurate approach and be flexible enough to provide services with healthcare resources available on-island. JABSOM can create training modules that simulate how medical students would interact with Pacific Islander communities.
The State of Hawaii can help by making the experience smoother and more easily accessible for island folks. Many from the USAPI travel to Hawaii for cancer care and have a difficult time accessing care. Healthcare clinics in Hawaii could assist by accommodating the specialized needs of cancer patients who come from the Pacific. Hawai`i is a central hub of the Pacific, so we should support our fellow Pacific Islanders.
Can you volunteer in the Pacific Cancer Programs?
Students interested in public health and cancer prevention and control, especially for USAPI populations, can volunteer with the Pacific Cancer Programs. Several students and former colleagues who spent time with our programs earned terminal degrees and continue to do transformative work in communities. From manuscript writing and publication to research assistance and public health programmatic work, there’s a wide range of possibilities based on interests that align with our program goals and activities. Volunteers should contact Dr. Palafox to determine whether our current projects and work environment can offer a meaningful work experience aligned with their personal goals and needs.
Learn more about the work of the Pacific Cancer Programs and its affiliated organizations in the Pacific Islands:
Pacific Cancer Programs
Live Healthy Guam
Palau REACH (Racial and Ethnic Approaches to Community Health) Project
Federated States of Micronesia REACH Project