An epidemic, defined as “a disease widely occurring in a community at a particular time,” describes the incidence of cancer on Guam and there's no better description for it. Besides the frequency of cancer occurrence with its attendant tremendous impact on the lives of patients and families, is the cost of therapy threatening literally to bankrupt the nation. Let us examine the two parts of the equation:
1. Frequency of cancer: It is higher on Guam than in mainland United States for various types of cancer, specifically, lung, head and neck, liver, cervix, colon and bladder. Not surprisingly, four of the six are directly related to the higher incidence of tobacco use, i.e., smoking! Liver cancer is related to a high incidence of untreated hepatitis B and C, and cervical cancer to untreated and undetected HPV infection in women. Obesity is so pervasive on Guam with the attendant diabetes, kidney failure, eye disease, and cardiovascular disease. It is also directly related to incidence of endometrial, intestinal, pancreatic, liver, colon, kidney, and breast cancers. In fact, the combination of smoking and obesity accounts for well over half of the diagnosed cancers, especially if we exclude prostate cancers which are common but usually rather indolent cancer.
2. Cost of cancer care: While Americans boast of having the world’s best medical care, this is said with either complete ignorance of what is available elsewhere or for political reasons also known as “fake news.” To be sure, the apex of care in the U.S. renown hospitals is second to none, but this care is available only to a very small number of people, often wealthy foreigners who come to the U.S. specifically to be treated there. The other 90%-plus find themselves in a morass of private or government insurances with terms and conditions that take legal help to define and where often the automatic response to a request for care is negative until the decision is appealed repeatedly. And while we keep hearing about the incredible advance in cancer care with new drugs appearing almost daily, these come with a price tag starting at $10,000 per treatment just for the drug, and repeated every two to four weeks. Even with a reasonable insurance plan, how many people are able to afford a 20% co-pay on these medications, especially with a $1,500 to $4,000 annual deductible for most private insurances? Then there is radiation therapy with a mean cost of tens of thousands of dollars and surgery also with a similar figure. And if there are insufficient skills on Guam to handle a particular problem, the knee-jerk reaction is to send the patient to Manila for care often far below Western standards.
While one may expand on the ways to improve the delivery of cancer care that far exceeds the present, it would be ridiculous without addressing the underlying cause – the lifestyles that cause or encourage cancer. Without change, the solution is somewhat analogous to developing better “iron lung machines” for polio patients in lieu of polio vaccinations to prevent the disease. And if there is a sizeable population that is obtuse to the harmful effects of their lifestyle, there are interventions that may make this more desirable, such as: meaningful taxation of harmful habits including on cigarettes and “garbage foods”; government-sponsored screening for pre-cancers such as Pap smears; vaccinations for hepatitis or HPV vaccinations in grade school; and positive incentives including lower insurance premiums for nonsmokers, or weight closer to norm, better education in schools and communities, and distribution of healthy diet information.
There is no cancer control on Guam or the continental U.S., but the system as is has been cobbled together from various and diverse entities, with little or no coordination, and different goals. While a situation like Guam – a small, isolated, contained community – it would be ideal for instituting a combined approach to cancer care, but it falls very far short on all incentives. Ideally, a government-sponsored cancer care center could coordinate all cancer programs for prevention and therapy, pay for and approve all investigative procedures, standardize treatment along with recognized protocols, organize a multidisciplined discussion of all patients, and be a nidus for excellent records and clinical trials, much like international standards. Reimbursement, whether by private or government insurances, would pay for services to the center and the center staff would have to approve all outside expenses. Not only would the center run a profit as most private cancer centers now do, but this would eliminate the problem of obtaining drugs (which would be far cheaper to a government center than a private clinic), the denial by insurances for coverage, the duplication of services which is now rampant due to the discoordination of health care, as well as greatly reduce in-patient hospital care, and tremendously curb the overall cost to patients and insurers. However, seeing the total lack of interest in even simple health care improvements by the Guam Legislature – except at a time of an upcoming election when words, not actions, predominate, as well as the pathetic response of Adelup to the crisis at the Guam Memorial Hospital, this is but another dream of what could be on Guam.
Dr. Samuel Friedman is the director of the Cancer Center of Guam in Tamuning.