Cancer in Guam and Hawaii: A comparison of two U.S. Island populations

Arecoline in buccal cells reflects Areca nut dose

Areca nut (AN) is a carcinogen; its chewing cessation is, therefore, of worldwide interest. However, cessation biomarkers are lacking. We sought to establish arecoline in chewers' buccal cells (BCs) as a biomarker for AN dose. Self-reported AN doses, expressed as the average AN load ("AANL"), the product of AN amount, chewing time, and chewing frequency, were correlated by regression analysis with chewers' BC arecoline, measured by liquid chromatography mass spectrometry. We then determined whether associations differed between Class 1 chewers (who consume AN alone or with slaked lime, leaf, and/or spices) and Class 2 chewers (who consume any combination of the aforementioned ingredients plus tobacco). Among the 103 chewers, 28 Class 1 and 39 Class 2 chewers had detectable arecoline levels, which were used for analyses. A linear regression of cube-root transformed AANL on equally transformed BC arecoline levels provided the best model fit; resulting slopes and corresponding correlation coefficients were 0.86 and 0.40 (p < 0.01) for all; 1.09 and 0.51 (p < 0.01) for Class 1 chewers; 0.35 and 0.17 (p = 0.29) for Class 2 chewers; and 0.94 and 0.45 (p < 0.01), and 0.79 and 0.37 (p = 0.08), respectively, for those who included or excluded lime. Relationships between AANL and BC arecoline levels were similar between chewers who included or excluded lime (p = 0.76), but less between chewing classes (p = 0.14). This provides confidence that BC arecoline can generally act as a reliable biomarker for AN dose, useful for estimating efficacy in AN cessation studies and population-based chewing assessments.

Cervical Cancer Incidence in the US-Affiliated Pacific Islands

Importance

The World Health Organization has called for eliminating cervical cancer as a public health problem. Accurate and up-to-date estimates of population-based cervical cancer incidence are essential for monitoring progress toward elimination and informing local cancer control strategies, but these estimates are lacking for the US-Affiliated Pacific Islands (USAPI).

Objective

To calculate age-standardized incidence rates for cervical cancer in the 6 USAPI and compare these rates with rates in the US (50 states and the District of Columbia).

Design, Setting, and Participants

This cross-sectional study used population-based data from the Pacific Regional Central Cancer Registry for women aged 20 years or older who were diagnosed with invasive cervical cancer from January 1, 2007, to December 31, 2020. The registry comprises data on all cervical cancers from the USAPI, which include 3 US territories (American Samoa, Commonwealth of the Northern Mariana Islands, and Guam) and 3 freely associated states (Federated States of Micronesia [FSM], Republic of the Marshall Islands [RMI], and Republic of Palau). Data were analyzed from July 10, 2023, to November 28, 2023.

Main Outcomes and Measures

The main outcome was age-standardized cervical cancer incidence rates, stratified by age, stage, and histologic code for the USAPI using population estimates from 3 different sources (US Census Bureau International Database, United Nations Population Division, and Pacific Data Hub). Rate ratios were calculated to compare incidence rates between the USAPI and the US.

Results

From 2007 to 2020, 409 cases of cervical cancer were diagnosed in the USAPI (median age at diagnosis, 46.0 years [25th-75th percentile, 39.0-55.0 years]), with an age-standardized incidence rate ranging from 21.7 (95% CI, 19.6-23.9) to 22.1 (95% CI, 20.0-24.4) per 100 000 women, depending on the population estimate. Incidence rates were highest in RMI, ranging from 58.1 (95% CI, 48.0-69.7) to 83.4 (95% CI, 68.3-101.0) per 100 000 women, followed by FSM, ranging from 28.7 (95% CI, 23.4-34.9) to 29.8 (95% CI, 24.3-36.3) per 100 000 women. Compared with the US, incidence rates were highest in RMI (rate ratio, 5.7 [95% CI, 4.7-6.8] to 8.2 [95% CI, 6.7-9.9]) and FSM (rate ratio; 2.8; 95% CI, 2.3-3.4). Of all cases in the USAPI, 213 (68.2%) were diagnosed at a late stage.

Conclusions and Relevance

In this cross-sectional study, cervical cancer remained a major public health issue in some USAPI, with RMI reporting the highest incidence rates. The findings suggest that improvements in human papillomavirus vaccination and cancer screening coverage through efforts tailored to the unique geographic, sociocultural, economic, and health care landscape of the USAPI may reduce the burden of cervical cancer.

Ethnic disparities in early-onset colorectal cancer incidence, screening rates and risk factors prevalence in Guam

Objective

Colorectal cancer (CRC) is one of the four most common cancers and the third leading cause of cancer-related deaths in Guam. This study investigated CRC incidence, screening, and risk factors of early onset CRC across Guam's ethnic groups using data from the Guam Cancer Registry (1998-2020) and the Guam Behavioral Risk Factor Surveillance System (2018-2019).

Methods

Incidence rate ratios (IRRs) were calculated to compare incidence rates across different age groups stratified by sex, ethnicity, and stage. Incidence rate differences (IRDs) were used to test for significant differences across sex and ethnicity. The Pearson chi-square test was used to assess differences in CRC screening rates by age, sex, education, income, healthcare coverage, and ethnicity, and to examine ethnic group disparities in the prevalence of CRC risk factors.

Results

The steepest increase in CRC incidence was observed between the 35-39 and 40-44 age groups (IRR = 2.01; 95 % CI: 1.14-3.53) and between the 40-44 and 45-49 age groups (IRR = 1.99; 95 % CI: 1.34-2.97). CHamorus exhibited rate increases at younger ages compared to Filipinos. CRC screening prevalence and associated risk factors showed considerable variation among ethnicities.

Conclusions

Elevated early-onset CRC rates were observed for both CHamorus and the broader Guam population under 50. The findings support the new recommendation to begin screening at age 45 and efforts to increase screening in Guam.

Disparities in Colorectal Cancer Incidence among Asian and Pacific Islander Populations in Guam, Hawai'i, and the United States

Colorectal cancer (CRC) ranks among the three most common cancers in Guam (GU), Hawai'i (HI), and the mainland United States (US). CRC prevalence in these areas is high among Filipinos, and indigenous CHamorus and Native Hawaiians; however, data on these populations are frequently aggregated in epidemiological studies, which can mask true CRC disparities. We examined CRC cumulative incidence rates (CIRs) among CHamorus in GU, Filipinos in GU, HI, and the US, and Native Hawaiians in HI and the US. CRC CIRs were calculated for two age groups (20-49 years; early onset, and 50-79 years; senior) and four time periods (2000-2004, 2005-2009, 2010-2014, and 2015-2019), stratified by ethnicity, sex, and location. Data analyzed included all invasive CRC cases reported to the Surveillance, Epidemiology, and End Results 9-Registry (n = 166,666), the Hawai'i Tumor Registry (n = 10,760), and the Guam Cancer Registry (n = 698) between 2000 and 2019. Senior CIRs were highest in HI and lowest in GU throughout all time periods, with a downward trend observed for senior CIRs in the US and HI, but not GU. This downward trend held true for all ethnic groups, except for CHamorus in GU, females in GU, and females of CHamoru ethnicity in GU. In contrast, early onset CIRs increased across all locations, sexes, and ethnic groups, except for Filipinos in HI and males of Filipino ethnicity in HI. Our findings provide crucial insights for future research and policy development aimed at reducing the burden of CRC among indigenous populations.

Utilizing Filipino key informants to guide community outreach for cancer prevention in Hawai'i

OBJECTIVE/DESIGN

The University of Hawai'i Cancer Center works with academic and community partners to examine health disparities and inequities that persist among Pacific Island Populations through the Pacific Island Partnership for Cancer Health Equity (PIPCHE). The Partnership's Community Outreach Core (COC) assists and promotes cancer research and helps to ensure the integration of historically excluded community perspectives by utilizing community-engaged and culturally-grounded approaches to reduce cancer burdens. However, cancer health disparities among Filipinos demonstrate a need for cancer-control initiatives within this community.

SAMPLE/MEASUREMENTS

COC staff conducted five semi-structured key informant interviews with Filipino nurse and healthcare leaders in Hawai'i to establishpartnerships with the community, as well as provide community-driven guidance for future cancer prevention and control efforts.

RESULTS

The informants provided recommendations for COC community engagement, relationship building, and future areas of directed cancer focus. The interviews also initiated relationship-building and community collaborations for directed cancer education and resources within Filipino communities.

CONCLUSION

The themes uncovered from the interviews provided guidance on how to begin addressing cancer concerns, and led to the informants' subsequent membership in our Outreach Advisory Council to engage in future collaboration with the Filipino community and a framework for future community-engaged cancer prevention efforts.

Barriers, Facilitators, and Strategies for Developing a Culturally Informed Lifestyle Intervention for Native Hawaiian, CHamoru, and Filipino Breast Cancer Survivors: Mixed-Methods Findings from Focus Group Participants

Breast cancer disproportionately impacts Native Hawaiian, CHamoru, and Filipino women. Few culturally informed interventions addressing breast cancer survivors exist and none have been developed or tested specifically for Native Hawaiian, CHamoru, and Filipino women. This study aimed to conduct focus groups with Native Hawaiian, CHamoru, and Filipino women previously diagnosed with breast cancer to inform future research in Guam and Hawai'i. Convenience sampling and grounded theory approaches were used. Focus group sessions were conducted during summer 2023 and included questions to understand the barriers, motivators, and implementation recommendations for lifestyle interventions aimed at reducing the risk for breast cancer recurrence among the target population. Data saturation was reached after a total of seven focus groups (an average of four survivors/group per site) were conducted (three in Hawai'i and four in Guam), which represented 28 breast cancer survivors. Themes from the focus groups emerged around developing support systems with other survivors, providing physical activity and nutrition intervention activities and materials in multiple formats, and incorporating activities and foods that accommodate the side effects of breast cancer treatments and are culturally relevant. The average desired intervention length was eight weeks. These findings will inform the development and feasibility testing of a culturally informed lifestyle intervention for breast cancer survivors in Guam and Hawai'i.

Traditional and new lifestyle interventions to prevent breast cancer recurrence (TANICA): a qualitative study

PURPOSE

Breast cancer is the second cause of death from cancer in Guam and Hawai'i and disproportionately impacts Native Hawaiian, CHamoru, and Filipino women. Although a few culturally informed interventions addressing breast cancer survivorship exist, none have been developed or tested for Native Hawaiian, CHamoru, and Filipino women. To address this, the TANICA study began with key informant interviews in 2021.

METHODS

Purposive sampling and grounded theory approaches were used to conduct semi-structured interviews with individuals experienced in providing healthcare or implementing community programs and/or research with ethnic groups of interest in Guam and Hawai'i. A literature review and expert consultation identified intervention components, engagement strategies, and settings. Interview questions aimed to understand the relevance of evidence-based interventions and explored socio-cultural factors. Participants completed demographics and cultural affiliation surveys. Interviews were independently analyzed by trained researchers. Themes were mutually agreed upon by reviewers and key themes were identified based on frequencies.

RESULTS

Nineteen interviews were conducted in Hawai'i (n=9) and Guam (n=10). Interviews confirmed the relevance of most of the previously identified evidence-based intervention components for Native Hawaiian, CHamoru, and Filipino breast cancer survivors. Ideas around culturally responsive intervention components and strategies emerged that were shared across and unique to each ethnic group and site.

CONCLUSION

Evidence-based intervention components appear relevant, yet cultural and place-based strategies are needed for Native Hawaiian, CHamoru, and Filipino women in Guam and Hawai'i. Future research should triangulate these findings with the lived experiences of Native Hawaiian, CHamoru, and Filipino breast cancer survivors to develop culturally informed interventions.

Oral Cancer Disparities in the Outer US-affiliated Pacific Islands

OBJECTIVE/HYPOTHESIS

Oral cancers in the US-affiliated Pacific Islands are poorly described despite disproportionately higher incidences in certain jurisdictions. This study attempts to better characterize the incidence, staging, and management of oral cancers in this region.

STUDY DESIGN

Retrospective Epidemiological Study.

METHODS

A retrospective review was conducted across the US-affiliated Pacific Islands between 2007 and 2019. Patient data were obtained for individuals with primary head and neck cancers from the Pacific Regional Central Cancer Registry database. All cohorts were age-adjusted to the 2000 US Standard Population. Further analysis was performed on oral cavity cancers due to their clear predominance within the sample.

RESULTS

A total of 585 patients with primary head and neck cancers were included. The average age was 54.5 ± 12.9 years, and most patients were male (76.8%). Oral cancer subsite analysis revealed the proportional incidence of buccal mucosa was higher in 5 of 9 jurisdictions when compared with the United States (p < 0.001). Tongue and lip cancers were not found to have significantly higher incidence proportions. Patients in the Pacific Islander group were less likely to be detected at earlier stages for cancers of the cheek and other mouth (p < 0.001), tongue (p < 0.001), and lips (p < 0.001) compared with the United States.

CONCLUSIONS

Many Pacific Island populations are burdened with higher incidences of oral cancer with later staging. Further investigation is recommended to evaluate oral cancer-related outcomes and mortality in this region.

LEVEL OF EVIDENCE

3 Laryngoscope, 2022.

Environmental Exposure to Cyanobacteria Hepatotoxins in a Pacific Island Community: A Cross-Sectional Assessment

(1) Background: Cyanobacteria produce a wide range of secondary metabolites, including tumor-promoting hepatotoxins. We recently reported evidence of an independent association between oral cyanobacteria and hepatocellular carcinoma in a U.S. population. We sought to characterize the nature, sources, and health correlates of cyanotoxin exposure in the U.S. Pacific Island territory of Guam, which has a high incidence of liver cancer. (2) Methods: Seventy-four adult males and females were enrolled in a cross-sectional study to quantify cyanotoxins in saliva, urine, and blood and their correlation with health behaviors, medical history, and environmental exposures. Plant samples were collected from locations throughout the island. Microcystin/nodularin (MC/NOD), cylindrospermopsin (CYN), and anabaenopeptin (AB) were measured in biospecimens and in plant extracts by ELISA. (3) Results: Overall, among study participants MC/NOD were detected in 53.9% of saliva, 7.5% of urine, and 100% of serum.; CYN in 40.0% of saliva, 100.0% of urine, and 70.4% of serum; AB in 30.8% of saliva, 85% of urine, and 92.6% of serum. Salivary MC/NOD levels were significantly higher in individuals using municipal tap water as their primary source of drinking water; both salivary and urinary MC/NOD levels were higher in those not using store-bought/commercial water. Urine MC/NOD levels were highest among individuals consuming fruits and vegetables exclusively from local sources. Urine MC/NOD levels were elevated in individuals with hypertension and hyperlipidemia and salivary MC/NOD in those with recent alcohol consumption. Cyanotoxins were prevalent in plant samples including MC/NOD (46.6%), CYN (35.1%), and AB (51.7%). (4) Conclusions: Our study provides evidence that exposure to cyanobacterial hepatotoxins, including tumor promoters, may be prevalent in Guam and may originate from environmental sources. Population-based epidemiologic studies are needed to investigate the role of cyanotoxins in liver cancer development.

Head and Neck Cancer Stage at Presentation and Survival Outcomes Among Native Hawaiian and Other Pacific Islander Patients Compared With Asian and White Patients

Importance

Research studies often group Native Hawaiian and Other Pacific Islander individuals together with Asian individuals despite being consistently identified as having worse health outcomes and higher rates of comorbidities and mortality. Native Hawaiian and Other Pacific Islander individuals also have high incidence rates of oral cavity and pharyngeal cancer compared with the general population; however, disparities in clinical presentation and survival outcomes of head and neck cancer squamous cell carcinoma (HNSCC) among this population have not been investigated nor compared with those of other races.

Objective

To determine the association of race with cancer stage at diagnosis and survival outcomes among Native Hawaiian and Other Pacific Islander patients with HNSCC compared with Asian and non-Hispanic White patients.

Design, Setting, and Participants

This was a retrospective population-based cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) 18 database. Asian, Native Hawaiian or Other Pacific Islander, and non-Hispanic White adult patients diagnosed in 1988 through 2015 with HNSCC of the oral cavity, oropharynx, nasopharynx, larynx, and hypopharynx were included; any patient whose record was missing data on disease or demographic information was excluded.

Main Outcomes and Measures

Cancer stage at presentation was compared among Asian, Native Hawaiian and Other Pacific Islander, and non-Hispanic White patients using a multivariable logistic regression model. Survival outcomes were compared among these racial groups using Cox regression models. Data analyses were performed from July 1, 2021, to March 20, 2022.

Results

The total study population comprised 76 473 patients: 4894 Asian (mean [SD] age at presentation, 60.7 [14.6] years), 469 Native Hawaiian and Other Pacific Islander (57.8 [12.3] years), and 71 110 non-Hispanic White (62.2 [12.1] years) individuals. Native Hawaiian and Other Pacific Islander patients were more likely to present with advanced-stage HNSCC (odds ratio [OR], 1.38; 95% CI, 1.12 -1.72) compared with non-Hispanic White patients. Asian patients presented with similar stage disease (OR, 1.04; 95% CI, 0.97-1.11) compared with non-Hispanic White patients. Native Hawaiian and Other Pacific Islander patients had worse disease-specific survival (HR, 1.18; 95% CI, 1.02-1.36) compared with non-Hispanic White patients after adjusting for clinical and demographic factors. In contrast, Asian patients had improved disease-specific survival (HR, 0.93; 95% CI, 0.88-0.98) compared with non-Hispanic White patients.

Conclusions and Relevance

This retrospective population-based cohort study suggests that Native Hawaiian and Other Pacific Islander race was associated with more advanced HNSCC, and worse disease-specific survival compared with non-Hispanic White race, while Asian race was associated with improved survival. This study highlights the importance of disaggregating Asian from Pacific Islander data when assessing health disparities, and the need for culturally sensitive interventions to promote earlier detection of head and neck cancer and improved survival among the Native Hawaiian and Other Pacific Islander population.

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.

Oral exposure to environmental cyanobacteria toxins: Implications for cancer risk

BACKGROUND

Areca nut/betel quid (AN/BQ) chewing, a prevalent practice in parts of the Pacific and Asia, is an independent cause of cancers of the oral cavity and esophagus and may be linked to liver cancer. The mechanisms of AN/BQ-associated carcinogenesis are unclear. In a Guam population, we previously demonstrated that AN/BQ chewing alters the oral bacterial microbiome including in chewers with oral premalignant lesions. Enrichment of specific taxa, including Cyanobacteria, was observed.

OBJECTIVES

We undertook an investigation to evaluate Areca catechu and/or Piper betle plants as potential sources of Cyanobacteria and cyanotoxins in AN/BQ chewers in Guam.

METHODS

We evaluated bacterial 16S rRNA with Illumina MiSeq in 122 oral samples and 30 Areca catechu nut and Piper betle leaf samples. Cyanobacteria sequences were interrogated using the NCBI database to identify candidate species and their reference sequences were evaluated for secondary metabolite toxins using AntiSMASH 5.0. Selected toxins were measured by ELISA in extracts from 30 plant samples and in a subset of 25 saliva samples.

RESULTS

Cyanobacteria was the predominant taxa in Areca catechu and Piper betle plants, comprising 75% of sequences. Cyanobacteria was detected at low levels in oral samples but 90-fold higher in current AN/BQ chewers compared to former/never chewers (p = 0.001). Microcystin/nodularin was detected in saliva (15 of 25 samples) and Piper betle leaves (6 of 10 samples). Cylindrospermopsin was detected in all saliva and leaf samples and 7 of 10 nut/husks. Salivary cylindrospermopsin levels were significantly higher in current chewers of betel quid (i.e., crushed Areca catechu nut wrapped in Piper betle leaf) compared to those chewing Areca nut alone. Anabaenopeptin was detected in saliva (10 of 25 samples), all leaf samples, and 7 of 10 nut/husks. Salivary anabaenopeptin concentration was weakly, albeit significantly, correlated with oral Cyanobacteria relative abundance.

DISCUSSION

Our study demonstrates that Cyanobacteria can contaminate AN/BQ plants and expose chewers to potent hepatotoxins. With worldwide increases in climate-related overgrowth of Cyanobacteria, our findings have broad implications for cancer risk across populations.

An Instagram-Based Study to Understand Betel Nut Use Culture in Micronesia: Exploratory Content Analysis

BACKGROUND

A 2012 World Health Organization report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. However, compared with other addictive substances, little is known about how betel nuts are depicted on social media platforms. In particular, image-based social media platforms can be powerful tools for health communication. Studying the content of substance use on visual social media may provide valuable insights into public health interventions.

OBJECTIVE

This study aimed to explore and document the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut in Guam and other parts of Micronesia.

METHODS

An exploratory content analysis of 242 Instagram posts tagged #pugua was conducted based on previous research on substance use and Instagram and betel nut practices in Micronesia. In addition, the study examined the social engagement of betel nut content on the image-based platform.

RESULTS

The study findings revealed content themes referencing the betel nut or betel nut tree, betel nut preparation practices, and the unique social and cultural context surrounding betel nut activity in Guam and Micronesia. In addition, certain practices and cultural themes encouraged social engagement on Instagram.

CONCLUSIONS

The findings from this study emphasize the cultural relevance of betel nut use in Micronesia. These findings provide a basis for empirically testing hypotheses related to the etiological roles of cultural identity and pride in shaping betel nut use behavior among Micronesians, particularly youths and young adults. Such research is likely to inform the development of culturally relevant betel nut prevention and cessation programs.

Cumulative Incidence Rates of Breast Cancer by Age for Filipinos and Chamorros in Guam

Breast cancer is the second leading cause of cancer-related death among women on Guam and Hawai'i. Breast cancer incidence rates are described here for the multiethnic population in Guam, a United States (US) Pacific island territory, and compared to Hawai'i and other US populations, to understand the risk by age and race/ethnic group in this understudied group. The study included all breast cancer cases (n=576) reported to the Guam Cancer Registry, all breast cancer cases (n=8345) reported to the Hawai'i Tumor Registry and all breast cancer cases (n=678,637) reported to the Surveillance, Epidemiology, and End Results program from 2000 to 2009. Cumulative incidence rates by age were calculated for two time periods: 2000-2004 and 2005-2009. Differences were seen in cumulative incidence rates by age, ethnicity, and place of residence. Cumulative incidence rates by age 40 were the highest (0.7%) among Filipinos in Guam but, after age 40, the rates for Chamorros (indigenous Pacific Islanders of Guam) increased rapidly. The lifetime cumulative incidence rates were the highest for Chamorros in Guam (15.3%), close to the US rate (15.5%). Results were similar for 2005-2009. Women in Guam are at high risk for breast cancer, with the indigenous Chamorros having the highest risk, and the most prevalent Asian group of Filipinos, having a younger age at diagnosis. These patterns are similar to the comparable Pacific Islander and Filipino populations in Hawai'i and the US generally.

Cultural Considerations for Conducting the Health Information National Trends Survey with Micronesian Communities: Lessons from a Qualitative Study

A critical barrier to addressing health disparities among minorities is the lack of data, particularly on Pacific Islanders. Typically, national health surveillance systems do not have the resources to ensure proper representation of these small population groups. This study reports factors that guided the cultural adaptation and administration of the National Cancer Institute's Health Information Trends National Survey (HINTS) for a United States-dwelling Pacific Islander population in Hawai'i. To adapt the survey, four focus groups were conducted with 32 purposively-selected Micronesian migrants. Themes on health, healthcare barriers, cancer and methods to implement the survey were extracted from the analyses of the focus group narratives. Key cultural factors were identified that impact health practices, including religious and cancer fatalism, racism, health locus of control and other barriers. Using information from the focus group participants, the HINTS questionnaire was modified and the survey was implemented. The survey data provided will inform the future delivery of health promotion strategies for this unique medically underserved population.

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.

Design and Outcomes of a Community Trial to Increase Pap Testing in Pacific Islander Women

BACKGROUND

Pap tests remain an essential cervical cancer detection method in the United States, yet they are underutilized among Pacific Islanders (PI) who experience elevated cervical cancer incidence and mortality. This study describes the design, methods, participants, and outcomes of a multiyear (2010-2016), community-based randomized intervention trial in southern California. Based upon strong collectivistic norms, the trial tested the efficacy of a unique social support intervention targeting Chamorro, Samoan, and Tongan women and their male husbands/partners.

METHODS

A single-session educational intervention was designed and tailored for ethnic- and gender-specific groups to increase men's social support for their female wives/partners to receive a Pap test, and for women to receive a Pap test. The comparison group received preexisting brochures on Pap testing (for women) or general men's health (for men). Pretest and 6-month follow-up data were analyzed.

RESULTS

Intervention and comparison groups were mostly equivalent on pretest demographics and outcome variables. Intervention women who were not compliant with Pap screening recommendations at pretest were significantly more likely to have scheduled and received a Pap test at 6-month follow-up. However, 6-month follow-up results indicated no intervention effect on changes in women's Pap testing knowledge, fatalistic attitudes, or perceived social support from their male partner.

CONCLUSIONS

Ethnic- and gender-tailored community interventions can successfully increase Pap test behaviors for PI women, although more research is needed on the specific pathways leading to behavior change.

IMPACT

Collaborative community-based interventions lead to increases in women's cancer prevention and early detection for Pacific Islander and other collectivistic communities.

A Unique Partnership Between the University of Hawai'i Cancer Center and the University of Guam: Fifteen Years of Addressing Cancer Health Disparities in Pacific Islanders in Hawai'i and Guam

This manuscript describes the efforts in research, education, and outreach of a unique partnership between the University of Hawai'i Cancer Center and the University of Guam in addressing cancer health disparities faced by Pacific Islanders in Hawai'i, Guam, and other parts of Micronesia. Significant accomplishments of this 15-year collaboration in research, training Micronesian students, and impact on the local communities are highlighted.

Together we can: Collaborative Efforts to Reduce the Cancer Burden on Guam and Save Lives

Cancer remains the second leading cause of death for Guamanians. Guam Cancer Registry (GCR) for two decades has provided epidemiological and demographic data needed to understand the unique cancer burden in Guam. Cancer data, along with data on behavioral risk factors and screening, have helped public health practitioners to target areas of need in cancer prevention, control, and research for Guam and our Pacific neighbors. These targeted efforts enable efficient use of limited resources. While cancer in its many forms remains a formidable foe, we now have a toolbox of evidence-based interventions (EBI), culturally-appropriate programs, community-based coalitions, and research unique to our region. Quality cancer data will remain a key component of this toolbox. This paper reports on the most recent cancer data for Guam for 2007-2015, and Guam's progress toward finding a "cure for cancer" through screening, early detection and treatment, and local research. Together, we can.