Chamorros, Carolinians, Cancer, and Creativity in the Northern Marianas

FormalPara Key Points

• Indigenous Pacific Islander Chamorros and Carolinians had little access to local cancer care in the Northern Mariana Islands before 2019.

• In 2019, the arrival of a medical oncologist and the development of an oncology treatment team led to patients receiving more comprehensive, state-of-the-art, local cancer treatment, but with challenges requiring creative solutions.

• An important part of the cancer program is cancer prevention and screening.

The Commonwealth of the Northern Mariana Islands (CNMI) comprises 14 islands north of the US Territory of Guam in the Northwestern Pacific Ocean, approximately 1500 miles from Japan and the Philippines, and nearly 4000 miles west of Hawai‘i. The largest island is Saipan. The islands in this Micronesian archipelago were settled several thousand years ago by peoples sailing from Southeast Asia who became Chamorro Indigenous Pacific Islanders. Carolinians arrived in the mid-1800s from the Caroline Islands near New Guinea. In 1987, the CNMI emerged from the Trust Territory of the Pacific Islands (TTPI), which the United States administered on behalf of the United Nations after 1947. Today, this island group is a US commonwealth territory, with over 40% of the population of 50,000 made up of Indigenous Pacific Islander Chamorros and Carolinians (the rest are largely immigrant Asians). The median household income in 2010 for a Chamorro family of four was about $30,000 and for a Carolinian family of four about $20,000. In the mainland United States, it was over $60,000.

Healthcare on the island is largely provided by the public Commonwealth Healthcare Corporation (CHCC), which runs the only hospital in the territory and administers all public health programs. Some patients are seen in outlying clinics by private providers. Financing of health services is based on the US model. Medicaid (US and locally funded medical insurance for the poor) provides healthcare for over 60% of the population. Medicare (US government insurance for the elderly, disabled, and patients with kidney failure on hemodialysis), Aetna, and other small private insurers provide coverage for the rest. Many immigrant Asians have no health insurance at all.

Challenge

Prior to 2019, no oncology physicians were available in the CNMI. When a patient developed cancer requiring treatment, they would travel off-island to a distant US jurisdiction or to the Philippines—if it was possible to travel at all. The local government has a variably funded medical referral program, a legacy of the TTPI, which arranges for off-island appointments, travel, lodging, food, and medical care. However, because of this variable funding and logistical challenges, often off-island care was not possible. For islanders, off-island care is always difficult, due to anxiety, uncertainty, fear of the unknown, an unfamiliar and intimidating medical environment, absence of supportive extended family, prolonged stays (sometimes months or years), estrangement from their community, and added financial burden. Almost no one with cancer could continue working while off-island. Furthermore, if patients died off-island, bringing them home would have incurred a high cost.

Developing a Cancer Program

In 2019, a medical oncologist began working full-time in the CNMI for the first time in its history. Many of the 200+ patients newly diagnosed with cancer each year began to receive cancer care without leaving the CNMI. A cancer care team was assembled, comprising cancer-oriented pharmacists, oncology nurses, nurse practitioners, physicians’ assistants, and internists with an interest in oncology. The team’s mission was to provide state-of-the-art, local, and culturally sensitive oncology care to the Chamorros, Carolinians, and others in the CNMI community.

Establishing the first oncology clinic led to improvements in other on-island diagnostic services, such as the availability of an interventional radiologist for expedited tissue biopsies, upgraded mammography with 3-D tomosynthesis, a faster CT scanner, and the addition of bone density radiography for osteoporosis in patients on estrogen deprivation therapy for breast or prostate cancer.

It quickly became clear to the oncology team that many Indigenous people with cancer in the CNMI had cancers that were related to certain lifestyle and traditional cultural norms and were highly preventable. Many in the CNMI still smoke cigarettes, and this leads to smoking-related cancers like lung cancer. A large number of Chamorros and Carolinians chew betel nuts, a habit that is discouraged but remains legal. In the Marianas, betel nut is inexpensive to grow and easy to buy. Over 20 Chamorros and Carolinians each year present with oral cancers that are typically very advanced and life-threatening. Aggressive treatment of advanced oral cancers off-island typically involves extensive surgical excision, radiation, and reconstructive surgery, resulting in gross facial deformities, impaired speech, poor nutritional intake, and social isolation/self-ostracization.

The high prevalence of obesity, hypertension, and diabetes predisposes patients to endometrial cancer. In addition, many have cancers that would have been caught at much earlier stages if they had received appropriate cancer screening, such as mammograms for breast cancer, HPV testing/Pap smears for cervical cancer, and low-dose CT scans of the chest for lung cancer. Some patients with chronic hepatitis B infections are not offered treatment or liver surveillance, resulting in a late diagnosis of hepatocellular carcinoma.

Prior to 2019, many patients with significant symptoms from progressive cancer such as pain, constipation, anorexia, nausea, and anxiety also experienced a lack of comprehensive palliative care. Today, many patients with advanced cancer and serious symptoms receive a comprehensive assessment of ways to help them feel more comfortable, and they are often visited at their homes by a medical provider trained in palliative care.

After 2019, the hospital’s vision of cancer control began a focus on cancer prevention, screening, and treatment, led by the newly formed oncology department. Referrals for off-island care fell dramatically, saving costs for the government and hospitals. Furthermore, patients presented with cancers at earlier stages, and hence were easier to treat. Patients now often receive their care entirely in the CNMI, without leaving their jobs, family, and friends. We believe that cancer care for Pacific Islanders can now be provided at a level that often equals or exceeds that received by mainland US residents.

Treatment Challenges: A Case Report

There are ongoing challenges in cancer control in the CNMI, including procurement of expensive anti-cancer medication (e.g., immunotherapy such as pembrolizumab), and this is where creativity in devising solutions has been necessary. The program is able to obtain certain expensive medications for patients at no cost through patient assistance programs offered by some drug companies, resulting in savings of thousands of dollars. This is illustrated in the following case study of a CNMI patient who had a large disabling oral cancer and was unable to travel.

Patient X (identifying information has been removed) is a 63-year-old man with diabetes and receiving hemodialysis for end-stage kidney disease. He’s very frail and uses a wheelchair for mobility. He’s completely unable to travel off-island for medical care. In 2021, he presented with a large mass covering his mouth, arising from the right inner cheek and lower lip. He’d been a lifelong betel nut chewer. The mass he had went unnoticed during his dialysis sessions as he had been wearing a mask to protect against COVID-19. Eventually, he could not get any food into his mouth, and the mass would often bleed and hurt (see Fig. 51.1).

Fig. 51.1

Patient’s initial presentation: Massive oral tumor arising from the lower lip. (Photo: P Brett)

In the mainland United States, the patient would be considered too frail for surgery but could have received six weeks of palliative radiation treatment. This would shrink the tumor, but not likely cure it. In the CNMI, he would have to travel off-island for radiation and would have to continue dialysis off-island, which he was unable to do. The creative solution was to identify medications likely to shrink the cancer for a time without causing substantial side effects (as chemotherapy can do), which the patient would be able to tolerate. The patient was given IV immunotherapy (pembrolizumab) and IV anti-epidermal growth factor treatment (cetuximab), and the cancer has gradually shrunk, now for two years. The patient’s quality of life has improved substantially, and he can eat, drink, and talk normally. Furthermore, he’s had almost no side effects. The cancer may still grow back, but probably not for many months to years. Figure 51.2 shows the patient after one year of treatment, and Fig. 51.3 after two years of treatment.

Fig. 51.2

Patient after one year of treatment: Tumor is substantially smaller. (Photo: P Brett)

Fig. 51.3

Patient after two years of treatment: Tumor has nearly resolved. (Photo: P Brett)

We have learned that having medical oncology available in the CNMI allows for sophisticated, often creative treatment that sometimes obviates the need to refer off-island for radiation treatment or complex cancer surgery, which is still not available in the CNMI. Many patients are still unable or unwilling to travel. Often, systemic cancer treatment is given as the only possible treatment in the absence of viable alternatives. Patients often derive substantial benefits from such measures.

Prevention/Screening Challenges

Another complex challenge faced by Indigenous Pacific Islanders is poor access to cancer screening and prevention. If no one smoked, fewer people would develop lung cancer; if no one chewed betel nut, fewer people would develop oral cancer; if all young women received the HPV vaccine, fewer would develop cervical cancer; if people were screened regularly for lung cancer (if smokers), colon, cervical, breast, and oral cancers, treatment would be far more successful, since cancers would be detected earlier.

The oncology team set up a cancer screening and prevention program subsidized by the hospital, with the expectation that medical costs would decrease when cancer is prevented or detected early, rather than treated at advanced stages. About 500 patients have entered the screening/prevention program so far. However, to have a real impact, we believe 10,000 patients per year will need to take part. We currently think the biggest barriers are a lack of community awareness and too few healthcare workers to perform screening. Our creative solution is to have community healthcare workers do much of the program intake and community outreach, with tests reviewed by medical providers. We are also preventing maternal-to-child hepatitis B virus transmission with mandatory screening of expectant mothers and vaccination of all newborns.

Conclusion

A two-pronged approach of providing expert medical oncology care to Indigenous Pacific Islanders (as well as other Asians in the CNMI community) and no-cost screening and prevention should save many lives in the CNMI community and improve quality of life. However, this will require health promotion and education programs developed for and with Indigenous populations to support healthier habits and mitigate the risk of developing cancer, especially the cessation of betel nut chewing and tobacco use. In addition, targeted initiatives to promote cancer screening programs and support Indigenous people to participate in regular cancer screening programs, which are now available on the island, are essential.

The long-term sustainability of this on-island cancer treatment and prevention program requires stable funding and the availability of trained, interested medical practitioners. The island’s medical infrastructure is fragile, and we hope that there will be enlightened creative government leadership that places healthcare services as one of its highest priorities.