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Native Hawaiians and other Pacific Islanders suffer disproportionately from cancer. These groups are more likely than other ethnic groups in the US to be diagnosed at late stages of disease and to die from cancer. They also are less likely to be up-to-date with cancer screening, and they are more likely to engage in lifestyle practices that increase their risk of cancer, eg, they are more likely to be overweight and less likely to engage in physical activity than many other ethnic groups.1–6
Although some generalizations can be made about Pacific Islanders in comparison to Caucasians, there are also differences among Pacific Islander groups. For this discussion, we distinguish Native Hawaiians in Hawai'i from other Pacific Islanders in Hawai'i and Pacific Islanders in the US-affiliated Pacific Island Jurisdictions (which include American Samoa, the Commonwealth of the Northern Marianas, the Federated States of Micronesia [FSM], Guam, Republic of the Marshall Islandbbs [RMI], and Republic of Belau).
Like other indigenous Americans, Native Hawaiians face barriers to timely cancer diagnosis and treatment in their own homeland. These barriers include lack of knowledge about cancer, fear, poverty, lack of insurance, and lack of access to cancer care, as well as cultural barriers in the system and complacency in standard medical care.1,2 Some Native Hawaiians still view cancer as a death sentence, and those with cancer report high anxiety while waiting for a definitive diagnosis, the treatment plan, and services.2 They feel that doctors provide them a menu of options, even though patients do not have enough information to make good choices.3 The state's geography also presents challenges, because the bulk of cancer care resources are centered in Honolulu. Most neighbor island cancer patients must travel or relocate to Honolulu for diagnosis and treatment; both options impose financial, physical, and mental stresses.2 Thus, high costs, lack of (or inadequate) insurance, lack of providers, and high burdens associated with traveling to Honolulu often dictate treatment decisions.1–3
An estimated 35,000 non-Hawaiian Pacific Islanders reside in Hawai'i. More than half are Samoans, and most others are from the RMI (Republic of the Marshall Islands) and the FSM (Federated States of Micronesia).4,5 There are no reliable population-based estimates of breast and cervical cancer prevalence or screening utilization in these populations, either in their home countries (due to lack of tracking infrastructure) or in the US (due to small population numbers).4–6 Although American Samoa, RMI, and FSM have Centers for Disease Control and Prevention (CDC)-funded Breast and Cervical Cancer Control Programs (BCCCP), capacity and reach are limited.6 Once in Hawai'i, these groups underutilize BCCCP services, likely due to lack of awareness about the importance of screening and the recommended screening guidelines, lack of awareness about BCCCP, lack of financial resources for copayments, and lack of transportation to mammography units.4,5 Awareness of prostate and colorectal cancer screening guidelines are even more limited.4 Thus, for this group many cancers are caught in late stages when treatment options are reduced.4–6
Cancer in this US-affiliated Pacific has gained US attention because of its association with its thermonuclear weapons testing. Testing has poisoned the land, and residents of Bikini atoll (RMI) still cannot eat food grown there due to high radiation levels in the soil. Residents of Kosrae and Pohnpei States (FSM), who participated in the clean-up of the nuclear detonation sites, also were affected, and radioactive strontium from the weapons testing was documented to have reached the shores of Guam.6,7 Socioeconomic conditions in these jurisdictions are poorer than in most areas of the US.6 Overcrowding, poor hygiene, and underdeveloped public works systems contribute to the social production of illness, including high rates of hepatitis, Helicobacter pylori, dengue fever, cholera, filariasis, leptospirosis, pneumonia, and sexually transmitted diseases. At the same time, prevalence of obesity, diabetes, and heart disease are increasing.6 Hospitals are located in capitals, and jurisdictional health departments support small clinics or lay health workers in population centers outside the capital. However, the clinics have limited services, and hospitals have limited beds; complex cases often are sent off-island, eg, to the Philippines or Hawai'i. The capacity to screen for cancers of the breast, cervix, colon/rectal, and prostate is limited due to lack of equipment, supplies, trained personnel and limited laboratory capabilities. Limited awareness about cancer screening and insufficient infrastructure to perform screening tests increase the risk of late-stage diagnosis of cancer, and the region has almost no capacity to treat cancer, especially late-stage cancer.6
Momentum in the past decade to address cancer health disparities among Native Hawaiians and Pacific Islanders is increasing.8–12 Since 2000, 'Imi Hale– Native Hawaiian Cancer Network (U01- CA114630), has trained and supported more than 100 Native Hawaiian researchers and increased community-based participatory research and programming addressing cancer health disparities among Native Hawaiians.8,9 Supported by the National Cancer Institute Center to Reduce Cancer Health Disparities (NCI-CRCHD), 'Imi Hale is one of 25 Community Network Programs in the US. The Pacific Cancer Initiative of NCI-CRCHD convened the Cancer Council of the Pacific Islands in 2003, with representatives from the US-associated jurisdictions.6,10 This group has assessed cancer needs in the region and then was awarded CDC funds for cancer care planning and implementation.6,10–11 Cancer Patient Navigation and peer-educator programs have been developed for Native Hawaiians and Micronesians in Hawaii,3,5,12 and interest is growing in American Samoa to do the same. These efforts signal a start to the attention and awareness needed to address some of the worse cancer health disparities in the world—those experienced by Native Hawaiians and Pacific Islanders.
This article is part of “Marketplace of Ideas II—Voices from the Community.”