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

Abstract

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.

Introduction: Cancer Health Disparities in Pacific Islanders

Despite tremendous advancements in cancer research as well as scientific discovery, not all populations have benefited equally, as disparities continue to persist among specific populations andfor numerous types of malignancies. Moreover, educational andresearch opportunities are not equally available to all; populationgroups that experience the greatest health disparities are also significantly underrepresented in the US biomedical research and health care workforce, further exacerbating cancer and other health disparities.

In the Hawai‘i-Pacific region, Americans of Pacific Islander ancestry continue to experience significant disparities in cancer risk due to lifestyle, genetic, and environmental factors, along with limited cancer awareness and education, poor access to cancer screening, late-stage diagnosis, and limited cancer treatment options. Thus, this group is burdened by poor treatment outcomes. For example, geographic, educational, and resource barriers contribute to the highest rates of cervical cancer in Micronesiawhereincidencein Micronesian womenis 8-fold higherthan the US national average (79.7/100,000 vs 9.9/100,000). Cervical cancer incidence in Guam was nearly double the rate in Hawai‘i for the period of 2009-2013.^1,2 Compared to men in Hawai‘i, men in Guam, particularly Chamorros (Guam’s indigenous population), are disproportionately affected bypoor outcomes for a number of major cancers including those involving the lung and bronchus, nasopharynx, liver, and intrahepatic bile duct. Rates of liver and intrahepatic bile duct cancer among men in Guam were nearly double, and nasopharyngeal cancers were more than quadruple higher than those of men in Hawai‘i.^1,2

The University of Guam/University of Hawai‘i Cancer Center Partnership

In 2018, the University of Guam (UOG) and University of Hawai‘i Cancer Center (UHCC) marked 15 years of continuous funding awarded by the National Cancer Institute (NCI) to supportcollaborativeresearch, training, andoutreachtoaddresscancer health disparities in Americans of Pacific Island ancestry.The UOG/UHCC Partnership is one of only 14 partnerships within NCI’s Partnerships to Advance Cancer Health Equity (PACHE) program. Since 2001, the PACHE program has supported partnerships between NCI-designated cancer centers and minority-serving institutions that aim to investigate cancer health disparities and their impact on racial/ethnic minorities, medically underserved, and socio-economically disadvantaged populations. The UOG/UHCC Partnership is the only partnership within the PACHE program that addresses cancer health disparities in Pacific Islanders. The program focuses especially on Micronesians in Hawai‘i and Guam, but also in other USAPI jurisdictions.

Through the UOG/UHCC Partnership, the PACHE program has provided long-term infrastructure support for cancer research in the Hawai‘i-Pacific region, graduate training in cancer health disparities, mentoring and career development for early stage investigators (ESI) at the partnering institutions, outreach education for communities in Guam, Hawai‘i, and the USAPI, and funding for new and innovative cancer research projects of particular relevance to Hawai‘i, Guam, and the USAPI.

Research

In the current funding cycle (2015–2020), the UOG/UHCC Partnership has focused on two regionally relevant areas of research: betel nut use and cervical cancer. Betel nut is the fourth most commonly used psychoactive substance in the world. The nuts are chewed for cultural and religious reasons, as well as for their stimulant effects, by more than 600 million people concentrated in South and Southeast Asia as well as in Papua New Guinea and the USAPI, notably on Yap and Chuuk. The practice is spreading eastward in the Pacific as Micronesians migrate to neighboring jurisdictions, including Guam, Pohnpei, the Marshall Islands, and Hawai‘i where betel nut is locally harvested from the Areca palm tree and sold by neighborhood vendors catering to the Pacific Islander communities. Betel nut is classified by the International Agency for Research on Cancer (IARC) as a Group 1 carcinogen, and is associated with oral, oropharyngeal, and esophageal cancer, as well as oral lesions, gum disease, and oral submucosal fibrosis. When chewed in combination with tobacco, which is common, betel nut is also linked to cancers of the pharynx. Other additives that are used include the Piper betel leaf, calcium hydroxide, alcohol, and spices.

To date, 12 betelnut studies have been supported by the UOG/UHCC Partnership, including 3 molecular studies, 3 population studies,3 mechanisticstudies, and2preventionstudies, includingan intervention trial. In the current funding cycle (2015–2020), our partnership is funding an adult betel nut cessation trial in Guam. This is the first known randomized intervention trial, modeled after group tobacco cessation interventions. We are also conducting a pilot study exploring betel nut biomarkers in urine and saliva for use in validating betel nut use in human research; an oral microbiome study evaluating the influence of betel nut chewing on oral bacterial composition plus bacterial composition of the Areca (betel) nut and Piper betel leaf; and a study to identify molecular components of Areca nut responsible for promoting chronic inflammation, an important process in carcinogenesis. The partnership’s investment in betel nut research is of global and regional importance, as study findings will inform future public health interventions and clinical recommendations for betel nut users in the Pacific region and worldwide.³

Our research on cervical cancer includes a screening study tailored for Pacific Islander women in Guam and Hawai‘i. Researchers are testing the effectiveness of sending text messages in participants’ native languages that are designed to increase cervical cancer screening rates among Marshallese migrants in Hawai‘i and Chuukese migrants in Guam.

As our investigators pursue more sources of external funding, we expect that our research portfolio on cancer health disparitiesin Pacific Islanders will continue to grow.

Research Education

Cancer health equity in Pacific Islanders will require research that is designed and conducted by, for, and with Pacific Islanders. As such, the UOG/UHCC Partnership provides support through its Research Education Core for underrepresented graduate students and early stage investigators (ESI), such as postdoctoral fellows and junior faculty, in the form of graduate assistantships, training in cancer health disparities research, andmentoring and career development at the partnering institutions. At UOG, up to 4 master’s students per year are awarded 2 years of support from the partnership to pursue degrees in programs related to cancer health disparities. A research thesis is required of all master’s students supported by the partnership, and as a requirement for graduation. These students are also exposed to all projects currently funded by the partnership. At UHCC, the partnership supports up to 2 doctoral students each academic year, including 1 supported by NCI funds and another supported by UHCC institutional funds dedicated to the partnership. Together with their mentors, all master’s and doctoral students are required to develop a career development plan and to present their research thesis to the partnership team before completing their program. All students who work on research projects of the partnership, including those awarded graduate fellowships as well as others hired by partnership investigators, are encouraged to participate in additional courses and activitiesto strengthen their ability to conduct research related to cancer and health disparities in preparation for health and research careers in the Pacific region. Seven online training modules have been developed by UHCC and UOG faculty to support the training aims of the partnership.

In addition to supporting minority students in cancer health disparities research, thepartnership aims to supportand developunderrepresented ESI at UOG and UHCC. ESIs are mentored by partnership faculty to strengthen their research skills, such as those in research design, grant writing, navigating the institutional review board (IRB) process, working with community advisory boards, and other areas related to conducting, analyzing, and disseminating cancer health disparities research. ESIs are informed about and encouraged to participate in research training and career development opportunities made available through the partnership, the partnering institutions, the NationalInstitutes of Health (NIH), and other sponsors, including the NCI-funded Geographical Management of Cancer Health Disparities Program (GMaP, Region 5), which sponsors an annual career development workshop.⁴ The partnership also provides learning and career development opportunities through travel support available for students and ESIs to present at national conferences and meetings as well as summer travel and salary support for faculty, doctoral students and ESIs to conduct research, prepare manuscripts, develop research proposals, and engage in other professional activities in collaboration with faculty members at the partnering institutions.

These activities address the partnership’s overarching goal to develop scientists underrepresented in basic, clinical, translational, behavioral, and population research, while increasing the number of Pacific Islanders leading successful careers as health professionals and scientists committed to addressing cancer prevention and control priorities of island communities in the Pacific region.

Community Outreach

In addition to advancing the cancer health equity aims of the partnership, we conduct outreach activities which have been selected in response to the recommendations of community advisory groups at both UOG and UHCC. In Guam, outreach efforts have focused on increasing uptake of human papilloma virus (HPV) vaccination through provider education and community awareness initiatives. In addition, following the recent purchase of an inflatable colon, UOG’s outreach team is leading efforts to promote colorectal screening in Guam. In Hawai‘i, UHCC’s outreach team is working with members of Oahu’s Kosraean community and healthcare providers at Kapiolani Medical Center for Women and Children in Honolulu to identify and implement strategies to facilitate mutually trusting relationships and the delivery of culturally competent care.

Outcomes and Impact

Outcomes during the previous funding period (which began in September 2009) included significant scientific discoveries published in more than 70 peer-reviewed publications, a complete list of which is provided on our website: http://www.guamcrc.org. Other accomplishments include 16 grants awarded to partnership investigators, 8 faculty exchange visits, and support for 22 master’s students and 8 doctoral students. There are 4 PhD graduates of our programs at UHCC from Guam and other parts of Micronesia, including two who are now faculty at UOG and contributing as partnership investigators. Importantly, these graduates are already mentoring future scientists from Guam and other parts of Micronesia. In addition, a master’s level program in cancer health disparities was developed at UOG, and is now a part of the institution’s Micronesian Studies Program.

Community outreach activities resulted in landmark tobacco control legislation adopted in Guam, most importantly a significant increase in the tobacco tax. Modeled after a similar increase in Hawai‘i’tobacco tax, tobacco tax revenues in Guam are earmarked for cancer programs, including approximately $1 million in annual revenues to support cancer screening and direct patient services on Guam. In September 2016, through the work of partnership betel nut investigators, legislation prohibiting the sale of betel nuts to minors was adopted in the US Commonwealth of the Northern Mariana Islands.

The Guam Cancer Registry (GCR), once an unfunded legislative mandate, was developed into a fully operational cancer registry with help from the Hawai‘i Tumor Registry and NCI partnership funding. This registry is now an important resource for research and public health in Guam. Long-term sustainabilityof the GCR is now ensured by an earmarked portion of Guam’s tobacco tax.⁵

Conclusion

Infrastructure and resources for cancer research and surveillance were nonexistent in Guam prior to the establishment of the UOG/UHCC partnership in 2003. The partnership has significantly increased research capacity at UOG and cultivated interest and engagement in cancer research among underrepresented investigators as well as minority students alike. Scientists from a variety of disciplines and departments at both institutions are collaborating to address cancer health disparities in Guam, Hawai‘i and the neighboring USAPI. Pacific Islander populations, particularly Micronesians in Guam and Hawai‘i, are more aware of the risks associated with cancer, and providers are becoming more sensitive to the needs of these patients. While the partnership has made progress in its 15-year history, there is much more to be done to overcome the unequal burden of cancer in Pacific Islanders.

Glossary

ESI

Early Stage Investigators

GCR

Guam Cancer Registry

PACHE

Partnerships to Advance Cancer Healthy Equity

UHCC

University of Hawai‘i Cancer Center

UOG

University of Guam

USAPI

United States Associated Pacific Islands (Guam, Northern Mariana Islands, American Samoa, Republic of Palau, Federated States of Micronesia (which consists of the Kosrae, Pohnpei, Chuuk, and Yap States), Republic of the Marshall Islands)

Conflict of Interest

None of the authors declare any conflict of interest.