Comprehensive Cancer Control Plan for the Commonwealth of the Northern Mariana Islands 2007-2012

Objectives

The 2007–2012 Comprehensive Cancer Control Plan seeks a cancer-free Commonwealth of the Northern Mariana Islands (CNMI) through an integrated programme of prevention, screening, early diagnosis, treatment, longitudinal care, survivorship, palliative care, and strengthened cancer information.[1][2]Its overarching purpose is to reduce cancer incidence, morbidity and mortality while ensuring that residents can access education, appropriate care and ongoing support.[2][3]

• Prevent cancer and reduce controllable risks through tobacco and betel nut control, healthier nutrition, physical activity, reduced harmful alcohol use, infectious-disease prevention and vaccination, and reduced exposure to carcinogenic contaminants.[4][5][6][7]
• Increase early detection through evidence-supported breast, cervical and colorectal screening, public awareness, outreach to high-risk populations, and follow-up for abnormal findings.[8][9][10]
• Improve diagnosis and treatment by strengthening local clinical, laboratory, imaging and chemotherapy capacity, while maintaining access to off-island specialist care when services are unavailable in CNMI.[11][12][13]
• Strengthen longitudinal care by developing patient navigation, survivor tracking, palliative care, home-based support, pain and symptom management, and culturally appropriate end-of-life care.[14][15]
• Establish complete, accurate and timely cancer data systems, including a formal cancer registry, to support surveillance, planning, resource allocation and evaluation.[4][16][17]

The plan gives particular attention to cancers with an identified burden in CNMI, including lung, breast, cervical and colorectal cancers, alongside cancers of unknown origin.[18][19]It responds to serious service constraints, including late diagnosis, limited on-island specialist capacity, lack of oncologists, reliance on referral facilities in Hawaii and the Philippines, and financial hardship associated with off-island care.[20]

• Reduce adult smoking by 5% by 2012 and reduce youth smoking by 10% by 2012, alongside reducing the social acceptance of betel nut use and establishing CNMI-specific tobacco and betel nut treatment capacity.[21][22]
• Increase regular breast and cervical screening among CNMI women by 30% by 2012 and reduce breast and cervical cancer mortality to 10% by 2012.[10]
• Develop a colorectal screening database by 2009 and increase colorectal screening rates by 10% by 2012.[10][23]
• Vaccinate 10% of females aged 9–26 against human papillomavirus by 2011 and achieve hepatitis B vaccination completion for 90% of two-year-old children by 2012.[24]
• Establish a formal cancer registry by 2009 and expand public and workforce awareness and training in cancer information management.[16][17]

Implementation

Implementation is designed as a coordinated, coalition-based model linking public health, clinical services, community organisations, cancer survivors, businesses, schools, faith leaders, local government and regional and international partners.[1][3]The CNMI Cancer Control Coalition provides the principal collaborative platform, working with the Commonwealth Cancer Association, Department of Public Health, Commonwealth Health Center, Medical Referral Programme, Northern Marianas College and island health centres.[25][26][27]

• Govern delivery through a Steering Committee that sets timelines, guides data and communication priorities, identifies resources, recruits members and builds partnerships.[17]
• Coordinate implementation through an Executive Committee and core team comprising coalition leadership, a Programme Coordinator, Outreach Coordinator, Data Clerk or Registrar, and facilitators for prevention, screening, diagnosis, treatment, survivorship and palliative care.[28]
• Assign the Programme Coordinator to manage inter-agency work, data-sharing agreements, team meetings and implementation; assign the Outreach Coordinator to lead awareness activities; and assign the Data Clerk or Registrar to maintain data quality and the cancer database.[5]
• Use topic-specific implementation teams and workgroups for prevention, screening and early detection, diagnosis, treatment, longitudinal care, registry development, surveillance and evaluation.[17][29]

Service delivery combines population prevention with targeted clinical pathways. Prevention activities include media campaigns, school and workplace education, tobacco-control events, retailer education, culturally tailored materials, health fairs and community outreach.[30][21]Screening delivery includes weekly breast and cervical clinics, roaming village Pap clinics, community recruitment and structured follow-up for abnormal results.[9]Proposed mobile clinics and outreach teams are intended to reach high-risk populations, support tracking and reduce barriers related to transport, privacy, language and awareness.[10]

• Strengthen local diagnostic and treatment services through equipment and supply inventories, workforce training, improved imaging interpretation, chemotherapy-administration training and regular updating of cancer-care teams.[23][13]
• Coordinate patient navigation, cancer case management, referral records and Honolulu-based support for people requiring extended off-island treatment.[26][13]
• Develop regional collaboration through the Pacific Islands Health Officers Association and Cancer Council of the Pacific Islands for technical assistance, minimum indicators, referral coordination, laboratory support and cancer-data infrastructure.[31][27]
• Engage national partners, including the American Cancer Society, University of Hawaii, Centers for Disease Control and Prevention, National Cancer Institute and relevant regional cancer-control bodies, for planning, training, materials and technical support.[2][30][32]

Monitoring combines routine programme reporting, cancer surveillance and formal evaluation. The plan calls for monthly progress reports to the Regional Cancer Control Coordinator, cancer data collection from medical records and laboratory sources, quality assurance with hospital and regional registry staff, and coordination of referral information with cancer case management.[28][5][26]The Evaluation Committee is responsible for ensuring objectives are measurable, developing the evaluation framework, reviewing implementation and recommending adjustments to the Steering Committee.[17]It is expected to produce an annual progress report for presentation at a cancer control conference, while the wider plan is reviewed annually and updated as required.[33][3]

Financing is intended to build on existing prevention, screening and survivorship activity, but the source does not specify a complete plan budget or quantified financing gap.[27][32]Resource mobilisation includes grants, coalition partnerships, fundraising through the Marianas March Against Cancer, periodic donations, tobacco sin-tax advocacy, and financial assistance for qualifying patients.[4][31][32]

Monitoring & Evaluation

The plan establishes an evaluation and surveillance approach centred on annual review, measurable objectives, strengthened cancer data systems, registry development, service tracking and regional reporting. It treats the plan as a living document that should be updated in response to new information, opportunities and changing needs.[1][3][33]

• Review the plan annually to determine whether goals, objectives and strategies remain relevant, and update it where required.[1][3]
• Develop and oversee an evaluation protocol through the Evaluation Committee, which reports recommended adjustments to the Steering Committee and evaluates the Comprehensive Cancer Control Programme, coalition and implementation process.[17][33]
• Produce an annual progress report for presentation at a cancer control conference.[33]
• Assess infrastructure and capacity, stakeholder support, data gaps, coalition composition and satisfaction, cancer burden, and progress towards programme objectives.[17][33]
• Collect complete, accurate and timely data on cancer incidence, mortality, risk factors, screening, diagnosis and treatment services to support trend monitoring, programme evaluation, service planning and policy adjustment.[16]
• Establish a formal cancer registry by 2009, link it with the Pacific regional central registry, and create protocols covering screening, diagnosis, treatment, discharge summaries and off-island referrals.[16]
• Strengthen data quality through training in chart review, coding, cancer coding, analysis and reporting, alongside quality-assurance activities with hospital and regional registry staff.[5][16]
• Submit monthly implementation progress reports to the Regional Cancer Control Coordinator for regional compilation and distribution.[28]
• Maintain referral records through the medical referral programme logbook and coordinate these records with cancer case-management activities.[26]
• Track cancer treatment and service quality, patient follow-up, survivorship, recurrence and treatment-related side effects through proposed patient and survivor tracking systems.[32][13][15]

Specific targets include reducing adult smoking by 5% by 2012, reducing youth smoking by 10% by 2012, vaccinating 10% of females aged 9 to 26 against human papillomavirus by 2011, achieving 90% hepatitis B vaccine-series completion among two-year-olds by 2012, increasing breast and cervical screening by 30% by 2012, and increasing colorectal screening by 10% by 2012.[21][22][24][10][23]Nutrition, physical activity and alcohol objectives also use quantified targets and baseline measures where data are available.[34][35]

Regional bodies are expected to recommend minimum cancer-control indicators, and selected plan objectives are aligned with these indicators.[31][27]However, the available material does not provide a complete consolidated indicator set, a standard reporting template, a comprehensive evaluation methodology, or a fully specified accountability framework beyond the Evaluation Committee, Steering Committee, coalition arrangements, annual review and regional reporting mechanisms.[31][17][33]

Costing & Financing

Financing relies on a combination of federal and external grants, local government support, tobacco sin-tax revenue, charitable fundraising, donations and in-kind contributions. The plan identifies substantial resource constraints, particularly for off-island diagnosis, treatment, referral, follow-up and palliative care, but does not provide a consolidated costed implementation budget or quantified overall funding gap.[30][32][13][14][16]

• Use funding from the Centers for Disease Control and Prevention, the National Cancer Institute, the United States Department of Health and Human Services, Title X Family Planning and other grant mechanisms to support planning, screening, public-health programmes and cancer-control infrastructure.[2][30][28][9]
• Mobilise funds through the Commonwealth Cancer Association’s Marianas March Against Cancer, Relay for Life events, golf tournaments, family donations, business gifts and other fundraising activities.[4][31][32][33]
• Use proceeds for community outreach, treatment equipment, patient-support supplies and limited financial assistance for qualifying cancer survivors.[4][31][36]
• Seek to re-secure tobacco sin-tax revenue for tobacco prevention and cessation after no new allocation followed the initial funding delivered to the Commonwealth Health Center.[32]
• Administer grant receipts and expenditure through the Commonwealth of the Northern Mariana Islands Government accounting system in accordance with accounting principles, federal regulations and grant or cooperative-agreement conditions.[28]
• Identify funding for cancer databases, regional reporting, screening equipment, patient navigation, on-island treatment logistics, registry development and home-care options.[37][23][13][16]

The Commonwealth of the Northern Mariana Islands Medicaid programme spent 7,297,828 United States dollars in financial year 2004 against a capped federal allocation of 2,381,000 United States dollars, illustrating wider health-financing pressure.[38]Off-island care is repeatedly described as financially burdensome for patients, families and government services, especially where patients lack insurance, are ineligible for medical referral support or face transport costs between islands.[20][9][23][13]

Qualifying cancer survivors may receive up to 250 United States dollars annually for specified supportive expenses, although medicines, surgery, radiation, chemotherapy and travel are excluded.[4]The source does not specify total plan expenditure, activity-level costings, recurrent financing needs, allocation schedules, unit costs, economic assumptions or a quantified funding gap.[11][32][16]