Breast cancer incidence and stage at diagnosis in the six US-Affiliated Pacific Islands.

BACKGROUND: Breast cancer is the most common cancer diagnosed among women globally and in the United States (US); however, its incidence in the six US-Affiliated Pacific Islands (USAPI) remains less characterized. METHODS: We analyzed data from a population-based cancer registry using different population estimates to calculate incidence rates for breast cancer among women aged >20 years in the USAPI. Rate ratios and 95 % confidence intervals (CI) were calculated to compare incidence rates between the USAPI and the US (50 states and the District of Columbia). RESULTS: From 2007-2020, 1118 new cases of breast cancer were diagnosed in the USAPI, with 66.3 % (n = 741) of cases reported in Guam. Age-standardized incidence rates ranged from 66.4 to 68.7 per 100,000 women in USAPI and 101.1-110.5 per 100,000 women in Guam. Compared to the US, incidence rates were lower in USAPI, with rate ratios ranging from 0.38 (95 % CI: 0.36, 0.40) to 0.39 (95 % CI: 0.37, 0.42). The proportion of late-stage cancer was significantly higher in the USAPI (48.7 %) than in the US (34.0 %), particularly in the Federated States of Micronesia (78.7 %) and Palau (73.1 %). CONCLUSIONS: Breast cancer incidence rates were lower in the USAPI than in the US; however, late-stage diagnoses were disproportionately higher. Low incidence and late-stage cancers may signal challenges in screening, cancer surveillance, and health care access and resources. Expanding access to timely breast cancer screening, diagnosis, and treatment could reduce the proportion of late-stage cancers and improve survival in the USAPI.

Building Capacity for Cervical Cancer Prevention in U.S.-Affiliated Pacific Islands: The Pacific Against Cervical Cancer Project.

The U.S.-affiliated Pacific Islands (USAPI) have higher cervical cancer incidence and mortality rates and lower screening coverage compared with the United States. This is likely because of economic, geographical, health care delivery, and cultural barriers for women living in these resource-constrained, isolated regions. The most recent U.S. and World Health Organization cervical cancer screening guidelines recommended primary human papillomavirus (HPV) testing as one screening option or the preferred screening modality. Primary HPV screening-based strategies offer several advantages over current screening methods in the USAPI. However, adoption of this newer screening modality has been slow in the United States and not yet incorporated into USAPI screening programs. The U.S. Centers for Disease Control and Prevention and partners initiated the Pacific Against Cervical Cancer (PACe) project in 2019 to evaluate the feasibility, acceptability, and cost-effectiveness of primary HPV testing-based strategies in Guam and in Yap, Federated States of Micronesia. This report provides an overview of the PACe project and outlines the approaches we took in implementing primary HPV testing as a new cervical cancer screening strategy (including the option of self-sampling in Yap), encompassing four core components: (1) community engagement and education, (2) medical and laboratory capacity building, (3) health information and system improvement, and (4) modeling and cost-effectiveness analysis. The PACe project provides examples of systematic implementation and resource appropriate technologies to the USAPI, with broader implications for never screened and under-screened populations in the United States and Pacific as they face similar barriers to accessing cervical cancer screening services.

Strengthening cancer control in the South Pacific through coalition-building: a co-design framework.

Background: Cancer is a significant problem for the South Pacific region due to a range of complex health challenges. Currently gaps in diagnosis, treatment and palliative care are significant, and while governmental commitment is strong, economic constrains limit health system strengthening. Alliances have been successful in strengthening non-communicable disease and cancer control policy and services in resource constrained settings. A regional coalition approach has therefore been recommended as an effective solution to addressing many of the challenges for cancer control in the South Pacific. However, evidence regarding the effective mechanisms for development of alliances or coalitions is scarce. This study aimed to 1) create a Coalition Development Framework; 2) assess the use of the Framework in practice to co-design a South Pacific Coalition. Methods: Creation of the Coalition Development Framework commenced with a scoping review and content analysis of existing literature. Synthesis of key elements formed an evidence-informed step-by-step guide for coalition-building. Application of the Framework comprised consultation and iterative discussions with key South Pacific cancer control stakeholders in Fiji, New Caledonia, Papua New Guinea, Samoa and Tonga. Concurrent evaluation of the Framework utilising Theory of Change (ToC) and qualitative analysis of stakeholder consultations was undertaken. Findings: The finalised Coalition Development Framework comprised four phases with associated actions and deliverables: engagement, discovery, unification, action and monitoring. Application of the Framework in the South Pacific identified overwhelming support for a Cancer Control Coalition through 35 stakeholder consultations. Framework phases enabled stakeholders to confirm coalition design and purpose, strategic imperatives, structure, local foundations, barriers and facilitators, and priorities for action. ToC and thematic consultation analysis confirmed the Framework to be an effective mechanism to drive engagement, unification and action in alliance-building. Interpretation: A Coalition to drive cancer control has significant support among key Pacific stakeholders, and establishment can now be commenced. Importantly results confirm the effective application of the Coalition Development Framework in an applied setting. If momentum is continued, and a regional South Pacific Coalition established, the benefits in reducing the burden of cancer within the region will be substantial. Funding: This work was completed for a Masters of Public Health project. Cancer Council Australia provided project funding.

Feasibility of Healthy Beverages Policies in American Samoa and Federated States of Micronesia: Water and Coconut Water Only Community Interventions.

American Samoa and the Federated States of Micronesia (FSM) are two small Pacific Island nations that have some of the highest noncommunicable disease (NCD) mortality rates in the world. Supported by church leaders to address obesity as an NCD risk factor, American Samoa, and Chuuk and Kosrae States of FSM selected the implementation of healthy beverages as a nutrition intervention through a water- and coconut water-only pledge in church events. The consumption of water and coconut water was tracked. Across 105 church events in the three jurisdictions, the count of water bottles before and after events decreased from 142.8 to 22.3, the number of coconuts before and after events decreased from 19.6 to 1.2, and cups of water before and after events decreased from 52.9 to 7.6. The promotion of healthy beverages in church settings holds promise in the Pacific as a feasible, accessible, and culturally responsive nutrition approach, given limited access to other nutritional alternatives, e.g., fresh fruits and vegetables. Supplemental health promotion messaging to maintain knowledge and attitudes about healthy is recommended for future scaling up.

"Community 101 for researchers": an online training program to build capacity for ethical community-engaged research with Native Hawaiians and Pacific Islanders.

To address the history of unethical research and community distrust in research among Native Hawaiian and Pacific Islander communities, we developed the "Community 101 for Researchers" training program, which was launched in 2014 to enhance the capacity of researchers to engage in ethical community-engaged research. The purpose of this paper is to describe the development of this training program as well as its reach and feedback from participants. The Community 101 training program is a self-paced, 2-h online training program featuring community-engaged researchers from the University of Hawai'i and their longstanding community partners. Throughout the five modules, we highlight the historical context of Native Hawaiians and Pacific Islander populations in Hawai'i related to research ethics and use examples from the community as well as our own research projects that integrate community ethics, relevance, benefits, and input. To determine reach and gather participant feedback on the training, we extracted data from the user accounts. The training has been completed by 697 users to-date since its launch. Despite very little advertisement, an average of nearly 70 users have completed the Community 101 Program each year. The majority of the participants were located in Hawai'i though participants were also from other states and territories in the US, and international locations. The majority of participants were from universities in Hawai'i in 51 different departments demonstrating multidisciplinary relevance of the program's training. The general feedback from the 96 participants who completed an optional anonymous evaluation survey given at the end of the training was positive. The "Community 101 for Researchers" Training program is an accessible and relevant tool that can be used to advance ethical community engaged research, specifically with Native Hawaiian and Pacific Islander communities.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the State of Hawai'i.

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the world. To address the impact of COVID-19 in the state of Hawai'i, the Hawai'i Emergency Management Agency (HI-EMA) Community Care Outreach Unit conducted an assessment survey to determine the impact of COVID-19 on the health and social welfare of individuals and their families across the state. This article presents key statewide findings from this assessment, including areas of need and community-based recommendations to help mitigate the impact of the pandemic, particularly for vulnerable groups. A total of 7927 participants responded to the assessment survey from across the state's counties. In all questions related to paying for essentials, the percentage of participants that expect to have problems in the future, as compared to now, almost doubled. Slightly higher than one-third reported that they would know how to care for a family member in the home with COVID-19, and half of the respondents reported a lack of space for isolation in their home. About half reported that if they got COVID-19, they would have someone available to care for them. Overall, Native Hawaiian, Pacific Islander, and Filipino groups reported greater burden in almost all areas surveyed. The results presented provide a baseline in understanding the impact, needs, and threats to the health and social welfare of individuals and their families across the state of Hawai'i. Local stakeholders can utilize this information when developing priorities, strategies, and programs to address current and future pandemics in the state.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the City and County of Honolulu, Hawai'i.

To address the impact of COVID-19 in the state of Hawai'i, the Hawai'i Emergency Management Agency Medical Public Health Branch activated its' Community Care Outreach Unit (CCO Unit). A team from this unit developed a survey to assess the impact, needs, and threats to the health and social welfare of individuals and their families as they pertain to COVID-19. This article presents key findings for the City and County of Honolulu (CCH). A total of 5598 CCH residents responded. Approximately half of these respondents reported they or their household members experienced reduced work hours or lost their job as a result of COVID-19. In all questions related to paying for essential living costs, at the time of the survey, the percentage of participants who expected to have future problems nearly doubled. Those preparing for school in the fall school semester expected challenges centered on insufficient funds to purchase school supplies, lack of available face-coverings, and language barriers. Financial assistance, rental assistance, and food assistance seemed to be more difficult to apply for compared to health care services. The most common reasons for difficulty with applications noted by residents included that they could not figure out how to complete the form, did not have all the documents, or could not get through on the telephone. About one-half of CCH participants reported feeling nervous more than half of the days or nearly every day in the past 2 weeks. Most perceived the severity of COVID-19 to be moderate to very high. Less than half reported knowing how to provide care for someone in their family with COVID-19. Half of the CCH participants reported that they practice social distancing usually or all of the time, and the majority reported wearing a face-covering usually or always when outside of the home. A significant portion of respondents reported barriers for providing care for a household member exposed or infected with COVID-19. Such barriers included a lack of space in their home for isolation; not having enough cleaning supplies; no working thermometer in the home, or no family member available to care for them. The results presented may provide a baseline for understanding the impact, needs, and threats to the health and social welfare of individuals and their families in CCH and across the state of Hawai'i. Local stakeholders can utilize this information in developing priorities, strategies, and programs to address the pandemic as it continues to unfold and learn lessons for future pandemics.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare in the County of Hawai'i, Hawai'i.

The Community Care Outreach Unit (CCO) of the Hawai'i Emergency Management Medical/Public Health Services Branch conducted a survey to gauge the impact of coronavirus disease 2019 (COVID-19) on the health and social welfare of individuals and families in the state of Hawai'i. A mixed-methods framework was utilized for survey distribution; 7927 respondents participated in the survey. This article presents key findings for the state's Hawai'i County (HC). It presents a descriptive analysis of the data to provide a basic overview of the impact of COVID-19 in HC, as assessed in August-September 2020. A total of 936 participants from HC responded to the survey. Approximately one-third reported that they or their family members experienced reduced work hours, and one-fifth lost their jobs because of COVID-19. Many reported difficulties paying for many types of living essentials and expected these difficulties to increase in the near future. Challenges for the fall school semester included lack of access to funds for school supplies and face-coverings. The majority perceived the severity of COVID-19 to be moderate/very high and most had at least a moderate level of knowledge about risks for developing severe COVID-19. Approximately half reported maintaining social distancing usually/all of the time, and about two-thirds reported wearing a face-covering usually/always when needed. Other barriers for COVID disease prevention and response included a lack of space for quarantine/isolation of family members, not having enough cleaning supplies, low knowledge of how to care for a household member with COVID disease and not having someone available to care for them if they contracted the virus. The results provide a baseline for understanding the impact, needs, and threats to the health and social welfare of individuals and their families as a result of COVID-19 in HC. Local stakeholders can utilize this information when developing priorities, strategies, and programs to address the pandemic where needed.

A Historical and Contemporary Review of the Contextualization and Social Determinants of Health of Micronesian Migrants in the United States.

Hawai'i's Pacific Islander (PI) population has suffered a higher burden of coronavirus disease 2019 (COVID-19) infections, hospitalizations, and deaths compared to other groups in the state. The Hawai'i Emergency Management Agency Community Care Outreach Unit conducted an assessment across the state to gain an understanding of the impact of the COVID-19 pandemic on the health and social welfare of households. Survey data was collected from individuals across the state during a period of 3 weeks (August 12-September 5, 2020). The following are resulting recommendations from the Pacific Island community to mitigate the impact and disparities of the pandemic as immediate and medium-term structural requests: (1) ensure that Pacific Island communities are proactively represented in state and county committees that develop health interventions to ensure that relevant language and culturally tailored communications and strategies are included, (2) provide consistent funding and community centered support to ensure consistent COVID-19 impact services for the Pacific Island families, (3) enhance the capacity of PI health care navigators and interpreters through increased funding and program support, and (4) engage state policy makers immediately to understand and address the systemic structural barriers to health care and social services for Pacific Islanders in Hawai'i. These recommendations were developed to address the generational inequities and disparities that exist for Pacific islanders in Hawai'i which were exacerbated by the COVID-19 pandemic.

COVID-19 Containment Ship Model: A Case Study for Pacific Island Response.

The Republic of the Marshall Islands, American Samoa, the Federated States of Micronesia, and the Republic of Palau have been without any COVID-19 community transmission since the beginning of the global pandemic. The Commonwealth of the Northern Mariana Islands has experienced modest community transmission, and Guam has had significant COVID-19 community transmission and morbidity. Although several of these United States Affiliated Pacific Island jurisdictions made difficult strategic choices to prevent the spread of COVID-19 which have been largely successful, the built environment and the population density in the urban areas of the Pacific remain inherently conducive to rapid COVID-19 transmission. Rapid transmission could result in devastating health and economic consequences in the absence of continued vigilance and long-term strategic measures. The unique COVID-19 vulnerability of islands in the Pacific can be modeled through examination of recent outbreaks onboard several United States Naval ships and other marine vessels. The environmental characteristics that pose challenges to infection control on an isolated naval ship are analogous to the environmental characteristics of these Pacific island communities. Considering a collection of case studies of COVID-19 transmission on ships and applying to Pacific Island environments, provides a heuristic, easily accessible epidemiologic framework to identify methods for interventions that are practical and reliable towards COVID-19 containment, prevention, and control. Using accessible evidence based public health policies, infection risk can be decreased with the objective of maintaining in-country health and social stability. These case studies have also been examined for their relevance to current discussions of health care infrastructure and policy in the Pacific Islands, especially that of vaccination and repatriation of citizens marooned in other countries. The need for aggressive preparation on the parts of territories and nations not yet heavily exposed to the virus is critical to avoid a rapid "burn-through" of disease across the islands, which would likely result in catastrophic consequences.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare of the Native Hawaiian Population in Hawai'i.

Native Hawaiians (NHs) are among the most vulnerable groups at greater risk for coronavirus disease 2019 (COVID-19). To understand the impact of COVID-19 on the state's population, a 35-question cross-sectional survey was administered across the state of Hawai'i. NH data from the larger report are provided here. The findings indicate that the impact of COVID-19 is disproportionately affecting NH households in areas of income and housing stability, chronic disease prevalence, emotional wellness, and COVID-19 prevention. Short-, medium-, and long-term recommendations are presented as next steps to addressing the health inequities among NHs.

A Report on the Impact of the COVID-19 Pandemic on the Health and Social Welfare of the Pacific Islander Population in Hawai'i.

Hawai'i's Pacific Islander (PI) population has suffered a higher burden of coronavirus disease 2019 (COVID-19) infections, hospitalizations, and deaths compared to other groups in the state. The Hawai'i Emergency Management Agency Community Care Outreach Unit conducted an assessment across the state to gain an understanding of the impact of the COVID-19 pandemic on the health and social welfare of households. Survey data was collected from individuals across the state during a period of 3 weeks (August 12-September 5, 2020). The following are resulting recommendations from the Pacific Island community to mitigate the impact and disparities of the pandemic as immediate and medium-term structural requests: (1) ensure that Pacific Island communities are proactively represented in state and county committees that develop health interventions to ensure that relevant language and culturally tailored communications and strategies are included, (2) provide consistent funding and community centered support to ensure consistent COVID-19 impact services for the Pacific Island families, (3) enhance the capacity of PI health care navigators and interpreters through increased funding and program support, and (4) engage state policy makers immediately to understand and address the systemic structural barriers to health care and social services for Pacific Islanders in Hawai'i. These recommendations were developed to address the generational inequities and disparities that exist for Pacific islanders in Hawai'i which were exacerbated by the COVID-19 pandemic.

Hemodialysis in the Compact Nations of the US Affiliated Pacific: History and Health Care Implications.

Background: The epidemic of non-communicable disease in the Compact nations of the US Affiliated Pacific Islands and the associated renal complications drive the demand for hemodialysis. Limited healthcare budgets and a lack of trained human health resources in these areas make hemodialysis a challenging undertaking that may require significant sacrifices in competing health care priorities. Methods: Two nephrologists who developed hemodialysis in the US Affiliated Pacific Islands provide its history. Cost estimates of hemodialysis for the Compact nations are collected from a 2014 hemodialysis feasibility report. The experiences and outcomes of current hemodialysis centers in the United States and other island nations provide a framework by which to assess the potential benefit and impact of hemodialysis in the Compact nations. Discussion: A consideration of how and why different stakeholders value hemodialysis will be crucial because they will drive the public's response to the institutionalization of any new intervention or the cessation of any existing intervention like hemodialysis. Conclusion: Updated cost estimates for dialysis clinics and data on renal disease rates in the Compact nations will be necessary to make informed decisions about hemodialysis in the current health systems. In the meantime, it is essential to enhance current medical interventions and public health strategies to prevent kidney disease and decrease the risks for kidney failure. Such preventive interventions must be culturally appropriate, effective, cost-efficient, and sustainable in the unique context of the Pacific.

Addressing Cancer Health Disparities in the Pacific Peoples of Hawai'i, Guam, and the US Associated Pacific Islands Through Pacific-Focused Research Capacity Building.

Sociocultural, geographic, and biologic factors contribute to cancer health disparities (CHDs) in indigenous Pacific peoples (IPPs) in Guam, Hawai'i, and the US Associated Pacific Islands (USAPI). IPPs experience a greater burden of CHDs that are associated with late-stage diagnosis and poor survival outcomes compared with majority populations in the United States. A 16-year partnership between the University of Guam (UOG) and University of Hawai'i Cancer Center (UHCC) aims to advance health equity in Guam, Hawai'i, and the USAPI through cancer research, training, and outreach. Investigators at collaborating institutions study issues of regional and cultural relevance in IPPs, including breast, cervical, liver, and oral cancers and use of tobacco and betel nuts (Areca nuts). Junior faculty with IPP ancestry or those who are focused on CHDs in IPPs receive mentorship and career development opportunities, academic fellowships are provided for graduate students, and Pacific Island communities are engaged through a participatory development process. The partnership has generated more than 90 peer-reviewed publications, more than 100 abstracts, and 11 grant awards. Thirty graduate scholars from under-represented minorities have been trained, including two who are now UOG faculty and are conducting independent research, contributing to the partnership, and mentoring scientists of tomorrow. Participatory community engagement has contributed to the passage of significant cancer prevention and control legislation in Hawai'i, Guam, and Saipan. Research capacity at UOG has increased significantly, and research at UHCC has expanded to address issues unique to IPPs. Graduate students from under-represented minorities are pursuing careers in cancer research. A regional research infrastructure has been established to support team science, and research findings are informing public health policy and planning.

Cancer management in the Pacific region: a report on innovation and good practice.

Pacific island countries and territories (PICTs) face the challenge of a growing cancer burden. In response to these challenges, examples of innovative practice in cancer planning, prevention, and treatment in the region are emerging, including regionalisation and coalition building in the US-affiliated Pacific nations, a point-of-care test and treat programme for cervical cancer control in Papua New Guinea, improving the management of children with cancer in the Pacific, and surgical workforce development in the region. For each innovation, key factors leading to its success have been identified that could allow the implementation of these new developments in other PICTs or regions outside of the Pacific islands. These factors include the strengthening of partnerships within and between countries, regional collaboration within the Pacific islands (eg, the US-affiliated Pacific nations) and with other regional groupings of small island nations (eg, the Caribbean islands), a local commitment to the idea of change, and the development of PICT-specific programmes.

Cancer control in small island nations: from local challenges to global action.

Cancer is a leading cause of death in small island nations and is forecast to increase substantially over the coming years. Governments, regional agencies, and health services of these nations face daunting challenges, including small and fragile economies, unequal distribution of resources, weak or fragmented health services, small population sizes that make sustainable workforce and service development problematic, and the unavailability of specialised cancer services to large parts of the population. Action is required to prevent large human and economic costs relating to cancer. This final Series paper highlights the challenges and opportunities for small island nations, and identifies ways in which the international community can support efforts to improve cancer control in these settings. Our recommendations focus on funding and investment opportunities to strengthen cancer-related health systems to improve sharing of technical assistance for research, surveillance, workforce, and service development, and to support small island nations with policy changes to reduce the consumption of commodities (eg, tobacco and unhealthy food products) that increase cancer risk.

Cancer control in the Pacific: big challenges facing small island states.

This Series paper describes the current state of cancer control in Pacific island countries and territories (PICTs). PICTs are diverse but face common challenges of having small, geographically dispersed, isolated populations, with restricted resources, fragile ecological and economic systems, and overburdened health services. PICTs face a triple burden of infection-related cancers, rapid transition to lifestyle-related diseases, and ageing populations; additionally, PICTs are increasingly having to respond to natural disasters associated with climate change. In the Pacific region, cancer surveillance systems are generally weaker than those in high-income countries, and patients often present at advanced cancer stage. Many PICTs are unable to provide comprehensive cancer services, with some patients receiving cancer care in other countries where resources allow. Many PICTs do not have, or have poorly developed, cancer screening, pathology, oncology, surgical, and palliative care services, although some examples of innovative cancer planning, prevention, and treatment approaches have been developed in the region. To improve cancer outcomes, we recommend prioritising regional collaborative approaches, enhancing cervical cancer prevention, improving cancer surveillance and palliative care services, and developing targeted treatment capacity in the region.