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

Objectives

The Comprehensive Cancer Control Plan for the Commonwealth of the Northern Mariana Islands (CNMI) sets a vision of a cancer-free CNMI and seeks to reduce cancer burden through an integrated system of prevention, screening, diagnosis, treatment, longitudinal care, survivorship, palliative care, data collection and community action.[1]Its mission is to provide residents with cancer-prevention education, screening, early diagnosis and treatment, longitudinal patient care, and support for quality of life and survivorship.[1]

• Reduce cancer incidence and modifiable risks by addressing tobacco, betel nut, alcohol, unhealthy diet, physical inactivity, obesity, environmental contaminants and cancer-related infectious agents.[2][3][4]
• Detect precancerous conditions and cancer at the earliest possible stage, with particular focus on breast, cervical and colorectal cancer screening.[5][6]
• Improve access to diagnostic techniques and provide appropriate, quality cancer treatment as close to home as possible, reducing dependence on costly off-island referrals.[2][3]
• Support patients’ physical, social, mental and spiritual wellbeing throughout diagnosis, treatment, follow-up, survivorship and end-of-life care.[2][7]
• Strengthen complete, accurate and timely cancer reporting, registry development and surveillance to inform resource allocation, service planning and policy.[2][8]
• Develop supportive cancer-control policies and initiatives, including prevention, tobacco-control, screening, referral, care-quality and data-use measures.[1][9]

The plan responds to a substantial local cancer burden. Cancer was the second-leading cause of death during 1997-2001, accounting for 119 of 815 recorded deaths, or 14.6%.[10]Recorded cases during 1991-2001 were most commonly breast, lung, cervical, cancer of unknown origin and head and neck cancer.[11]Breast and cervical screening are initial priorities, particularly because cervical cancer incidence was reported as markedly higher among CNMI women aged 25-34 than in the United States.[12][11]

Several objectives are time-bound. The plan aims to reduce adult smoking by 5% and youth smoking by 10% by 2012, establish a locally specific tobacco and betel nut treatment specialist by 2012, and reduce social acceptance of betel nut use.[13]It also seeks to establish a formal cancer registry by 2009, identify an in-country cancer registrar by August 2008, and develop a family cancer-risk registry.[8][14]

Implementation

Implementation is designed as a coordinated, community-based and regional partnership led by the CNMI Cancer Control Coalition and involving public health authorities, the Commonwealth Cancer Association, health providers, patients and survivors, families, community organisations, businesses, schools, faith leaders and regional and international partners.[1][15]The plan is treated as a living document, subject to annual review and updating where goals, objectives and strategies are no longer relevant.[1]

• Govern implementation through a Steering Committee responsible for timelines, data and communication priorities, resources, partnerships and membership, supported by Communication and Evaluation Committees, implementation teams and topic-specific workgroups.[14][16]
• Coordinate operational delivery through a core team comprising a Coalition Chair, Programme Coordinator, Outreach Coordinator, Data Clerk or Registrar, area facilitators and assistant facilitators, with executive representation from the coalition, survivors, the Department of Public Health and the Commonwealth Cancer Association.[4]
• Deliver prevention through public education, schools, community events, media, tobacco-retailer education, culturally relevant materials, healthy-lifestyle initiatives, vaccination and environmental-health action.[17][18][19][20]
• Expand screening through weekly breast and cervical clinics, community outreach, mobile or roaming clinics, tracking and recall systems, and partnerships with women’s health, religious, business and village organisations.[6][21][22]
• Strengthen diagnosis and treatment by improving local equipment, staffing, provider knowledge, documentation and referral coordination, while developing partnerships for services unavailable in CNMI.[23][24][25]
• Develop patient navigation, survivor tracking, community support, palliative-care training, home-based terminal-care support and end-of-treatment information for patients returning from off-island care.[25][7]

Service delivery is constrained by limited local pathology, laboratory, oncology, radiology and surgical capacity, resulting in frequent referral to facilities in the Philippines, Hawaii and elsewhere.[26][27]The approach therefore combines local capacity-building with regional collaboration through bodies including the Pacific Islands Health Officers Association, the Cancer Council of the Pacific Islands and the United States-Affiliated Pacific Islands regional coalition.[28][29][9]

Data systems are central to implementation. The Data Clerk or Registrar is intended to collect data from medical records, laboratories and other sources, maintain the central database, and work with hospital quality-assurance and regional registry personnel on data-quality activities.[30]Providers at the Commonwealth Health Center are responsible for diagnostic data collection and reporting, with the database intended to report to the Regional Cancer Registry.[31]

Monitoring includes monthly discussions with the regional coordinator, monthly progress reports, annual plan review and an annual progress report for a cancer-control conference.[4][16]Evaluation is intended to assess programme and coalition performance, infrastructure and capacity, support levels, data gaps, partnerships, cancer burden and progress towards measurable objectives with baselines, data sources and target outcomes where possible.[14][16]

Financing combines governmental and external grants, cooperative-agreement support, local fundraising, donations and in-kind contributions, but a comprehensive plan budget is not specified.[1][32][15]The CNMI Government administers federal public-health grants through accounting systems aligned with federal regulations and grant requirements.[4]Funding pressures include off-island referral costs, constrained insurance coverage, lack of sustained local funding and the need for external support for screening follow-up, registry development and survivorship services.[21][33][8]

Monitoring & Evaluation

Monitoring and evaluation combine cancer surveillance, service tracking, annual plan review and coalition oversight. The plan treats data, registry and surveillance, together with implementation, evaluation and evolution, as core action areas, and requires annual review of whether goals, objectives and strategies remain relevant.[34][1]

• Establish a formal cancer registry by 2009, identify an in-country registrar by August 2008, and coordinate the Northern Mariana Islands registry with the Pacific regional central cancer registry.[14]
• Collect complete, accurate and timely data on cancer incidence, mortality, risk factors, screening, diagnosis and treatment services, using data to identify trends, inform resource allocation, evaluate education and guide policy adjustments.[7][8]
• Strengthen diagnostic-data collection and provider reporting at the Commonwealth Health Center, maintain a central cancer database, and support reporting to the Regional Cancer Registry.[31][30]
• Develop data-exchange agreements, quality-assurance processes for medical-record documentation, cancer coding and abstraction training, and collaboration with hospital quality-assurance and regional registry personnel.[30][14]
• Use existing evidence sources, including cancer deaths, hospital records, off-island referral databases and screening-programme records, while interpreting historic data cautiously where information is incomplete or unreliable.[35]
• Maintain breast and cervical screening tracking, integrate clinic and mobile-outreach records, and recall women at appropriate screening intervals.[22]
• Establish a colorectal screening database by 2009 for case management and surveillance, with follow-up procedures and documentation and coding improvements.[23]
• Establish survivor and patient tracking to monitor follow-up protocols, treatment complications, recurrence, secondary cancers and long-term treatment effects.[25][7]

Several measurable targets are specified. These include increasing regular breast and cervical screening by 30% by 2012, increasing colorectal screening by 10% by 2012, vaccinating 10% of females aged 9–26 against human papillomavirus by 2011, and completing hepatitis B vaccination in 90% of two-year-old children by 2012.[20][36][22][23]Prevention monitoring also includes targets for smoking, body mass index, diet, physical activity, alcohol initiation and leadership awareness of tobacco and betel-nut risks.[13][37][18][38]

Implementation monitoring includes monthly discussions with the regional comprehensive cancer control coordinator, monthly progress reports for regional compilation, and intended online posting of significant activities.[4]The Steering Committee oversees implementation timelines, data priorities, resources, membership and partnerships; the Evaluation Committee recommends plan adjustments, and an annual progress report is intended for presentation at a cancer-control conference.[14][16]

Accountability mechanisms include coalition monitoring of Department of Health cancer services, policy review, financial record-keeping and annual reporting by the treasurer to the CNMI tax authority.[9]The source does not specify complete indicator definitions, routine reporting requirements beyond the stated monthly and annual mechanisms, evaluation methods, independent evaluation arrangements or sanctions for non-performance.[9][4][16]

Costing & Financing

Financing relies on federal grants and cooperative agreements, local public-health administration, cancer-association fundraising, donations and proposed tobacco sin-tax revenue. The source does not provide a consolidated cancer-control budget, detailed programme costing, quantified plan-wide funding gap or economic assumptions.[1][15][4]

• Administer federal public-health grants through the CNMI Government accounting system, which records receipts and expenditure in accordance with accounting principles, federal regulations and grant or cooperative-agreement terms.[4]
• Use funding from the Centers for Disease Control and Prevention through a cooperative agreement with the University of Hawaii John A. Burns School of Medicine to support plan development.[1]
• Draw on National Cancer Institute funding for the 2002 needs assessment and health-promotion materials, and a 2004 Pacific Comprehensive Cancer Control planning grant to the University of Hawaii Department of Family Medicine and Community Health.[32]
• Use a 50,000 United States dollars regional implementation subcontract to the University of Hawaii Department of Family Medicine and Community Health for jurisdictional and regional implementation guidance.[29]
• Seek to re-secure tobacco sin-tax funding for tobacco prevention and cessation after no new allocation followed the initial funding delivered to the Commonwealth Health Center.[15]
• Mobilise resources through the Marianas March Against Cancer, which raised approximately 230,000 United States dollars in fiscal year 2005 for outreach, treatment equipment and eligible patient assistance.[2]
• Provide eligible cancer survivors with financial assistance of up to 250 United States dollars per year, excluding medicines, surgery, radiation, chemotherapy and travel.[2]
• Address financial pressures from off-island referrals, diagnostic testing, travel, accommodation and treatment, which can be inaccessible for uninsured people and impose substantial burdens on families and the Department of Health.[27][3]

Health-system financing constraints are substantial. In fiscal year 2004, the Medicaid programme spent 7,297,828 United States dollars against capped federal Medicaid funding of 2,381,000 United States dollars.[26]Screening funding also remains fragile: federal breast and cervical programme funding ended in October 2002, while Title X funding from October 2005 supported a weekly free clinic but not mammography.[6]

The plan identifies continued external funding for screening follow-up, annual screening, registry development, patient navigation, longitudinal care and home-care options as resource needs, but does not quantify their costs.[21][25][7][8]Vaccines for Children provides free human papillomavirus vaccines for eligible uninsured or Medicaid-eligible people under 19, while the HPV-Vac. Coalition and partners bear remaining vaccination and campaign-administration costs.[20]