Cancer in the Solomon Islands

Cancer Epidemiology 50 (2017) 176–183

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Cancer Epidemiology The International Journal of Cancer Epidemiology, Detection, and Prevention journal homepage: www.cancerepidemiology.net

Cancer in the Solomon Islands Alexandra Martiniuka,b,c,* , Rooney Jagillid, Eileen Natuzzie, John Wesley Ilopituf , Meltus Oipataf , Annie-Marie Christieg , Jefferey Korinih , Cassandra Vujovich-Dunni , William Yuj a

University of Sydney, Australia University of Toronto, Australia George Institute for Global Health, Edward Ford Building, 2000, Australia d General Surgeon and Medical Superintendent National Referral Hospital, Honiara, Solomon Islands e San Diego State University, School of Public Health, USA f National Referral Hospital, Honiara, Solomon Islands g Royal North Shore Hospital, Sydney, Australia h Gizo Hospital, Gizo, Solomon Islands i University of New South Wales, Australia j Hunter New England Health, Newcastle, 2305, Australia b c

A R T I C L E I N F O

A B S T R A C T

Article history: Received 26 January 2017 Received in revised form 26 April 2017 Accepted 29 April 2017

Introduction: The Solomon Islands, with a population of 550,000, has significant challenges in addressing non-communicable diseases, including cancer, in the face of significant economic, cultural, general awareness and health system challenges. Objectives: To summarise the existing knowledge regarding cancer in the Solomon Islands, to gather new data and make recommendations. Methods: A literature review was undertaken and cancer data from the National Referral Hospital, Honiara were analysed and are presented. Key stakeholders were interviewed for their perspectives including areas to target for ongoing, incremental improvements. Last, a health services audit for cancer using the WHO SARA tool was undertaken. Results: Breast and cervical cancer remain the first and second most commonly identified cancers in the Solomon Islands. The Solomons cancer registry is hospital based and suffers from incomplete data collection due to its passive nature, lack of resources for data entry and processing resulting in weak data which is rarely used for decision-making. The health system audit revealed system and individual reasons for delayed diagnosis or lack of cancer treatment or palliation in the Solomon Islands. Reasons included lack of patient knowledge regarding symptoms, late referrals to the National Referral Hospital and inability of health care workers to detect cancers either due to lack of skills to do so, or lack of diagnostic capabilities, and an overall lack of access to any health care, due to geographical barriers and overall national economic fragility. Conclusion: The Solomon Islands is challenged in preventing, diagnosing, treating and palliating cancer. Stakeholders recommend establishing specialty expertise (in the form of a cancer unit), improved registry processes and increased collaboration between the sole tertiary hospital nationwide and other Solomon health services as important targets for incremental improvement. © 2017 Published by Elsevier Ltd.

Keywords: Solomon Islands Epidemiology Cancer Health system

1. Introduction

* Corresponding author at: University of Sydney, Australia. E-mail addresses: [email protected] (A. Martiniuk), [email protected] (R. Jagilli), [email protected] (E. Natuzzi), [email protected] (A.-M. Christie), [email protected] (J. Korini), [email protected] (C. Vujovich-Dunn), [email protected] (W. Yu). http://dx.doi.org/10.1016/j.canep.2017.04.016 1877-7821/© 2017 Published by Elsevier Ltd.

The Solomon Islands is an island nation in the Melanesia region with an estimated population of 550,000 people spread over more than 900 islands [1]. The Solomon Islands is one of the least developed countries in the Pacific Region with a 2014 United Nations Development Program Human Development Index ranking of 157 of 187 countries [2]. The Solomon Islands experience a severe under resource of health professionals and

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in 2012 the ratio of fully trained doctors nationwide was 0.21 per 1000 people [3]. In particular, the Solomon Islands suffer from a lack of medical specialists. There are no oncologists or haematologists. Based on 2014 World Health Organization (WHO) data, there are an estimated 111.2 deaths per 100,000 persons [3] attributable to cancer in the Solomon Islands. Of these, Solomon Islanders who suffer from breast cancer, ovarian cancer and uterine cancer have poor age-standardized death rates [3]. The mortality to incidence ratio for cancer remains high: 0.87 for males and 0.65 for females [4]. Mortality also remains high for malignancies of varying types; notably, cervical cancer at 18.8 deaths per 100,000, while worldwide the cervical cancer age-standardised mortality rate is 6.8 per 100,000 [5]. Although the number of people with non-communicable diseases (NCDs), including cancers, is anticipated to increase exponentially in the Pacific Region by 2030 the prevalence and impact of cancer in the Pacific, and certainly in the Solomon Islands is largely unknown. Most reports and publications about cancer in the Pacific region are merged into international reports grouping the Pacific Islands into the Asia Pacific Region and thus this data is more reflective of the disease prevalence in Asia than the Pacific Islands. The current lack of Solomon Islands specific data is due to: limited financial resources, weak health system, lack of training, human resource issues, and lack of time to focus on any of the key aspects of cancer (prevention, screening, diagnosis, treatment, palliation, data systems, and research). 2. Objectives This paper aims to summarise the existing literature about cancer in the Solomon Islands, to present data from the Solomon Island cancer registry, and present health system audit data (national and provincial) regarding cancer detection, diagnosis, treatment and palliation; as well as make recommendations for ways forward. 3. Methods (1) Literature review (peer-reviewed, grey, national and provincial documents) The databases MEDLINE, EMBASE, and CINAHL were searched for the following MESH terms: cancer, Solomon Islands. (2) Qualitative research using email, phone and in-person communication with non-governmental organizations (NGOs), clinicians (local and in Australia, New Zealand and the United States), policy makers, and funding organisations to ensure no data on cancer were missed and to describe existing prevention, diagnosis and treatment of cancer in the Solomon Islands. (3) Descriptive data analysis of cancer registry data from Honiara from co-authors (TD, JK, JWI, MO). Data on the Solomon Islands Cancer Registry were obtained from an existing internal document and power point presentation from 2015. Data entered into the registry were obtained from: Histopathology reports, fine needle aspiration biopsy (FNAB) reports, Medical ward, Surgical ward, Gynecological ward, Paediatric ward, Cytology reports, Patient’s medical records, and Death certificates from the National Referral Hospital. The data from the registry were collected between January 1st 2014 and December 31st 2015. (4) Descriptive data analysis of gastrointestinal (GI) cancer data from co-authors (EN, RJ) emerging from a new collaboration between Solomon Islanders, and American gastrointestinal and surgical specialists. (5) Medical record reviews in the Solomon Islands in order to present de-identified case vignettes to provide qualitative experience of cancer in the Solomon Islands.

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(6) Health systems and services audit and readiness for cancer using the WHO SARA Health services audit tool, conducted at the National Referral Hospital and one of 7 Provincial Hospitals. This tool was modified for cancer and the Solomon Islands by coauthors (AM, AC, JK). 4. Results 4.1. Literature review 4.1.1. Overview of the health system and socioeconomic context The island nation faces increasing socioeconomic challenges including urbanisation (although 80% of the population still live a subsistence lifestyle on remote islands), climate change, and environmental disasters such as earthquakes and poverty [7]. Approximately 22.7% of the population live in poverty (2010) with 1% of household income spent on healthcare [7]. The Solomon Islands face a growing burden of NCDs whilst combating communicable diseases [7]. The public healthcare system depends on a five-tiered healthcare system with seven provincial hospitals and one national referral hospital (NRH). None of the provincial hospitals had access to surgical or specialist services as of 2016; although minimal surgical services are planned for at least 2 provincial hospitals in the near future. Seventy-three percent of all medical personnel are based in the capital however 80% of the population lives on rural islands [7]. Health clinics and provincial hospitals remain under-developed, with up to 70% of area health clinics experiencing infrastructure degradation [7]. This unequal distribution of healthcare is underpinned by a severe health workforce deficit with an estimated 0.21 doctors per 1000 people [7]. Patients often bypass the existing tiered system by travelling directly (frequently by boat, on average 240 kilometres1) to the NRH. Infrequently, patients travel internationally for their healthcare needs [7]. This international travel is nearly fully for NCDs, including cancer and is a “significant and fast-growing component of government health expenditure that benefits a small fraction of the population” [8]. There is an important imperative to ensure equitable and appropriate referrals overseas and to evaluate whether such schemes are cost-effective. High quality data is sparse in a country that has to prioritise curative treatment and has little to no budget for data collection, cleaning and analysis; data are typically derived from estimates from neighouring countries [4,7,9]. There is no data on accessibility and appropriateness of cancer care including any palliative care [9]. Whilst the existing healthcare system has quality management and infrastructure evaluation [7], there are no audits to deliver information on cancer presentations, treatment times and outcomes. The Solomon Islands face a significant health financing challenge that affects development [10]. In the Solomon Islands 65% of health care is covered by the government, 29% is covered by external development partners and the remaining 6% from out of pocket payments [6]. For the Solomon Islands in 2013 about 5% of GDP was spent on health. This is double the typical percent of GDP spent on health in Low and Middle Income Countries (LMICs).This share of GDP spent on health is growing for most countries in the Pacific and, according to a recent World Bank Report this is unlikely to be sustainable financially in the future. Increased spending may not only be what is needed as existing resources could be used to improve effectiveness, efficiency, and equity of the health services [10,11]. Economic modelling data by the World Bank published in June 2016 demonstrated that by 2040 cancer will be responsible for 9% of the lost economic output for the Solomon Islands [12]. Typically lost economic output is driven by loss of working adults due to early death, and although this lost economic output is less in the Solomon Islands where the majority of its people live a

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subsistence lifestyle, it still represents an impediment to economic development. Even once past the significant logistic and economic hurdles of a diagnosis of cancer, there remain enormous barriers to successful healthcare delivery. Therapeutic options and primary prevention remain limited [13]. The execution and dissemination of public health campaigns, such as the ‘Fight Like a Girl,’ a campaign to raise awareness of Pap smear testing, remain in their infancy and face an uphill battle against social stigma, because they are viewed as having ‘broke(n) cultural customs’ [14]. Half of women requiring mastectomies do not have the procedure because losing one’s breast is considered making oneself less ‘womanly’ [1] and is avoided, leading to loss of life [1]. Whilst data is scarce, the majority of high priority and preventable malignancies in the Solomon Islands appear to remain unchanged over decades. In 1983, Taylor reported that the more common malignancies associated with mortality in males were skin, lympho-haematopoetic, and oral cancers, whilst in females, they were genito-urinary, skin, breast and lympho-haematopoetic cancers [15]. In 2003, Lumukana and King reported 48 cases of oral cancer between 1994 and 97 and 1999 at the NRH [16]. Of these, 43 out of 48 patients both smoked tobacco and chewed betel nut. The authors demonstrated that 83% of these cases chewed more than 5 betel quid per day. A second review in 2010 by Moore et al. of the broader Pacific Island region reported that oral and cervical cancers remain the most prevalent cancers in the male and female populations respectively [17]. And two malignancies (breast and cervical) could have potentially good outcomes if treated with a good standard of care currently comprise an estimated 43.3% of cancer mortality in women in the Solomon Islands [9]. 4.2. Screening, prevention and risk factors Screening systems are in their infancy. Pap smears for cervical cancer are available in 4 centers nationwide, so only 1–2% of 280,000 women nationwide uptake Pap smear tests, compared to over 40% uptake in other countries [18]. When smears are collected the basic histology can take between two to six months for a result [13,14]. This is particularly worrisome, as in the Solomon Islands cervical cancer is the second most common cancer amongst females aged 15 to 44, with an average of 57 new cases diagnosed every year and 31 deaths [19]. It is likely that opportunistic screening using visual inspection with acetic acid (VIA) is also occurring but there are no data on this. Since the existing HPV vaccine protects against 70% of all cervical cancer [20] in 2015, the Australian Cervical Cancer Foundation (ACCF) helped launch a SBD $8million vaccination program [21] to be introduced over 2 years at an estimated cost of $USD 4.5 per vaccination. Similarly, the installation of the first mammogram in the country in 2015 will hopefully provide better health outcomes to patients by detecting breast cancers earlier [1]. Since 2011, a Solomon Island, American, and English partnership has provided endoscopic and colonoscopy screening and has been able to detect and treat early esophageal, gastric and colon/ anal cancers [22]. For GI cancers, while there are no published Solomon Island specific data, one study from 2005 suggests that Helicobacter pylori infection (H. pylori) which causes chronic inflammation and significantly increases the risk of developing duodenal and gastric ulcer disease and gastric cancer, is very common in the Pacific Islands [23]. The study, which took place in a family clinic in Pohnepi, in the Federated States of Micronesia, found an infection rate of 94% in asymptomatic patients and 99% in symptomatic patients [23]. H. pylori may be a significant problem in the Pacific Region.

The highest incidences of Hepatitis B are in Southeast Asia and the Pacific Region where transmission is largely vertical from mother to child. In the Solomon Islands an estimated 19.6% of the population is seropositive for Hepatitis B antigen [4]. When acquired in childhood, Hepatitis B progresses to cirrhosis or cancer in 15–25% of individuals, and therefore represents a major cause of mortality in endemic settings. Chronic infection with hepatitis B and hepatitis C has been linked to the development of hepatocellular carcinoma, including liver and gall bladder cancer [24,25]. In 2006, the Solomon Islands conducted the WHO Stepwise Approach to Surveillance (STEPS) survey to collect data on the established risk factors for NCDs [26]. From the WHO STEPS survey the Solomon Islands has data on tobacco, alcohol and obesity. (1) Tobacco: Tobacco consumption in the Solomon Islands is 45% for males and 18 percent for females, compared to the global average of 21% [26,27]. The Solomon Islands has enacted a Tobacco Control Act in 2010 to combat aggressive marketing from tobacco companies [28]. Local action, such as posters in health clinics, is being taken to educate and prevent oral cancers from local brew and betel nut chewing (Supplementary Image #1). (2) Alcohol: Excessive alcohol consumption is associated with certain cancers in the Solomon Islands [8], data from the STEPS survey show that 56% of men drink alcohol (or kwaso, a local brew) but only 18.5% of women. For both men and women, frequency of drinking is low with <2% of people drinking on 4 or more days per week [26]. (3) Obesity: 23% of males are obese and 38% of females are obese in the Solomon Islands [27]. Additionally, in terms of risk factors, betel quid chewing is popular in the Solomon Islands [29]. In 2004; IARC declared that chewing betel quid without tobacco is carcinogenic to humans, group 1. Several epidemiological studies based in Taiwan, have found that chewing betel quid contributed independently to the risk of developing oral and pharyngeal cancer [30,31] and oral precancerous lesions [29]. Oral and pharyngeal cancer remain prominent in the Solomon Islands [5]. Esophageal cancers in the Solomon Islands have been reported to be largely squamous cell carcinomas involving the mid portion of the esophagus which is in contrast to the distal distribution of adenocarcinomas of the esophagus seen in Australia and the United States. It has been hypothesized that this might be due to lower rates of reflux and Barrett’s esophagus in the Solomon Islands and instead the high prevalence of betel nut chewing and tobacco use which are reported in 60% and 40% of individuals respectively [29]. 4.3. Treatment options and special access schemes There is little to no data on treatment options and outcomes for cancer. Several healthcare providers from regional neighbours provide healthcare free of charge, whilst the Solomon Island government provides transportation and accommodation overseas for a very limited number of people with cancer [8]. International oncologists/paediatric oncologists are challenged by making equitable choices when the request to treat a Solomon Islander is raised, due to the ad hoc nature of international requests for treatment made on the ground commonly based on personal connections, rather than on clinical grounds and for a pre-specified number of patients per year. Oncologists and hospital administration (in the Solomon Islands and in Australia) have previously reported the need for decision making-tools in this regard to ensure a more equitable and standardised process.

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4.4. The Solomon Islands cancer registry One of the recognised methods to improve cancer related outcomes worldwide is to implement a successful National Cancer Control Plan (NCCP). In 2002, funded by the National Cancer Institute, a Cancer Council of the Pacific Islands was formed with two representatives from each Pacific Island. To support this, the WHO International Agency for Research on Cancer (IARC) announced the Pacific Island Hub in 2014 to support the development and maintenance of cancer registries [32]. The Cancer Registry in the Solomon Islands was initially established during the 1980s. However, records from that time could not be located, these would have been paper records and there were no sustained, organized facilities for national or even hospital based medical record storage in those times, while the current Cancer Registry recommenced in 2006. For many years however, this database could not be populated with data for several reasons; environmental crises with a focus on acute care as well as infrastructure and staff related issues which included lack of staff time and expertise to collect, enter as well as maintain data, and challenges with the computer software and hardware when the installed database programmed failed to operate. As of today, the Cancer Registry in the Solomon Islands consists of the NRH (in Honiara) cancer registry which is a hospital based registry and pathology tumour registry. It aims to record all inpatient and outpatient cancer diagnoses made at this single tertiary care hospital. The pathology tumour registry is from the hospital’s pathology laboratory data on histological/cytological samples. The Cancer Registry unit is staffed with two registered nurses. The primary sources of data are histopathology reports, death certificates, and clinical diagnoses. The registry utilizes a single computer with IARC recommended cancer registry software CANREG4. This software is an iteration of CANREG5, which provides functionality for future data linkage, identification of duplicates, registering and reporting multiple primary cancers. This computer requires repair, resulting in intermittent and only partially computerized data management. There is now a dedicated space in a room to store paper records and a second computer has been donated by Rotarians in Australia for use in 2017 given the needs that were highlighted during the process of writing this paper. Other issues include: without a unique identifying number in the health system, the cancer registry reveals the identity of individuals, which creates a significant issue with confidentiality and privacy. There is also a lack of trained personnel for all aspects of cancer registry work, surveillance, data entry, management, analysis and reporting including a lack of overarching governance. To further complicate the process, registering cancer outcomes is challenging due to difficulties with follow-up and weak communication between remote clinics, provincial hospitals and the NRH. As a result, the cancer registry suffers from incomplete data collection due to its passive nature (cases and variables are missed), the lack of data-entering and data processing/analysing facilities means that this data occasionally is not entered; and if it is, the data is rarely summarized for use in clinical or decisionmaking settings. This result in a lack of buy-in or interest in the work required to maintain an up-to-date and accurate cancer registry. Data from this hospital-based registry are presented (Table 1). The data presented here is as entered into the database. Cancer classification from the data provided proved challenging, with categories that may or may not have significant overlap. There was no information on staging. Classification by ‘clinical diagnosis’ or body part was frequently encountered highlighting again the

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Table 1 Top 10 Cancers by Incidence in 2014 and 2015 (Combined), Solomon Islands. Rank

Type

Incidence

Female (%)

1 2 3 4 5 6 7 8 9 10

Breast Cervical Thyroid Lymphoma Oral Lung Hematological Head and Neck Brain Gastric

94 84 44 39 38 32 27 23 20 19

99 100 86 27 47 46 52 34 64 26

Solomon challenge of lack of diagnostic tools, diagnostic specificity, late presentation of disease and a lack of effective therapeutic options precluding further investigation. Taking these caveats into consideration, in the Solomon Islands the most common cancers using combined 2014 and 2015 data (to increase stability of numbers) were: 1st Breast cancer = 94 people; 2nd Cervical cancer = 84 people; 3rd Thyroid = 44 people. 4.5. Gastrointestinal cancer data More detailed cancer data is available from an endoscopy/ colonoscopy development partnership between Solomon Island, Australian and American doctors and nurses. Under this partnership, from December 2011 through December 2014 there were 739 endoscopies, 80% were upper endoscopies. Of these: 54 (10%) of upper endoscopies and 19% of lower endoscopies diagnosed cancers [22]. The majority of esophageal and gastric cancers were being diagnosed at advanced stages, with patients already experiencing cachexia and malnutrition. Men were diagnosed with esophageal cancers (80%) more frequently than women (OR 2.65 95% CI 0.987.22, p = 0.047). 70% of histopathology confirmed esophageal cancers were squamous cell carcinomas and located in the mid portion of the esophagus. The majority of confirmed gastric cancers were adenocarcinomas. There was one case of mucosa associated lymphoid tissue (MALT) that was treated for H. pylori [22]. A total of 27 tumors (19% of colonoscopies) involving the lower GI tract were diagnosed. This included 22 in the colon and rectum and 5 involving the anus. Of the tumors confirmed by histopathology, the majority were adenocarcinomas and 93% were left sided lesions. Colon cancer tended to be diagnosed at an earlier age in women in this small cohort (n = 27 total). After controlling for age women were diagnosed with colorectal cancer more frequently than men (OR 3.74 95% CI 1.2-12 p = 0.018) [22]. The most common endoscopic interventions performed were variceal bandings and palliative esophageal dilations and stent placements for tumors. Of the surgeries performed 40% led to a palliative procedure. 4.6. Health system readiness for cancer prevention, diagnosis, treatment and palliation An audit of health system readiness to prevent, diagnose, treat or palliate for cancer was conducted. This audit was modelled after the WHO SARA tool [33] which was developed to assess LMICs’ health systems readiness in general. The audit was completed for the sole tertiary care hospital in the Solomon Islands, the NRH in Honiara and a second audit in one of the 7 provincial hospitals.

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4.7. Health system readiness for cancer at the National Referral Hospital As the only tertiary care hospital in the Solomon Islands, the NRH’s catchment area is the entire population of the country, estimated to be 589,837 in 2016. The hospital serves a dual function as a referral hospital for the entire country as well as a district hospital for the island of Guadalcanal’s population of over 90,000. All complex care, including all surgery in the entire country, is provided for at the NRH. Services include medical, all surgical care, paediatric care, obstetrics and gynaecology and ophthalmology. Emergency services are provided at the Accident and Emergency Center where on average over 4000 people are treated per month. There is no intensive care unit. The NRH is a government publicly funded hospital with 305 beds. All health centers can refer to NRH. Travel for the patient and one caregiver is funded by the government. The NRH is the main training hospital. The Ministry of Health (MOH) has an agreement with Fiji National University’s School of Medicine to have Solomon Island students and registrars at the University participate in clinical rotations at the NRH. There is no School of Medicine in the Solomon Islands. There is a multidisciplinary breast cancer conference held regularly and attended by medical, surgical and radiology specialists as well as trainees. The NRH outpatient departments see over 16,000 patients per year. There is no separate treatment area for oncology patients and no oncologists or haematologists. Chemotherapy is delivered by the surgical service and there is no radiation treatment available. The specific chemotherapy agents on the Solomon Islands Essential Medicines list are: busulfan, carboplatin, cisplatin, cyclophosphamide, dactinomycin, doxorubicin, fluorouracil, hydroxycarbamide, imatinib, melphalan, mercaptopurine, and methotrexate, procarbazine and vincristine. Opioids on the essential medicines list, available for pain relief are: codeine, fentanyl, morphine, oxycodone, and pethidine. At least 15 cytotoxic agents on the WHO List of Essential Medicines are not available in the Solomon Islands. The NRH has a robust radiology department able to perform ultrasound, plain film with and without contrast and mammograms, and is in the process of obtaining its first CT scanner. It has the following laboratory services: routine blood counts and differential, blood chemistry, peripheral blood and microbiology. The lab can also test for HIV, Hepatitis B and C, malaria and dengue fever. The blood bank at the NRH can provide packed red cells and whole blood. There is roughly 1 nurse per 15 inpatients. Other health providers at NRH include a unit manager, a nutritionist and nursing aides. Nurses and community health workers (CHWs) provide services at the 46 community clinics and centers serving the main island and the 13 government funded clinics serving Honiara. The NRH has a 10 bed agreement with St Vincent’s Hospital in Sydney, Australia and patients in need of higher level care (complex cancers, cardiology) are referred there. The ethical and appropriate clinical selection of these patients can prove challenging as discussed above. 4.8. Health system readiness for cancer at the provincial level (Gizo) The catchment area of Gizo Provincial Hospital is 87,990 people. It is a government publicly funded hospital with 103 beds, and approximately 400 outpatient visits per year. Gizo has satellite centers from 6 zones referring to Gizo hospital. Gizo refers onward to Honiara 1–2 h travel away by plane. Gizo is a training hospital. There is no separate area for oncology patients. No surgery or anaesthetic capabilities are available. Gizo has the following laboratory services: routine blood counts and differential, blood chemistry, peripheral blood and microbiology. The blood bank at

Gizo can provide packed red cells and whole blood. There are no imaging services available and no radiotherapy. There are no oncologists, haematologists or paediatricians on site. There is 1 nurse per 30 inpatients. Other health providers at this Provincial Hospital include a unit manager and a nutritionist. There are CHWs providing services in the community. Methotrexate is the only chemotherapeutic agent available. Opioids are available for pain relief including oral morphine however some constraints affect availability into the country, as well as restrictions on which health professionals can prescribe it. Cancer cases are not registered or notified from the Provincial hospital and are not captured in the (NRH) cancer registry unless they are referred, and present at, the NRH. The majority of costs at Gizo Hospital as well as for referral to the NRH are paid by the government with some costs paid by religious groups. 5. Case study vignettes A Supplementary file contains two case study vignettes highlighting the journey of two Solomon Islander women with breast and cervical cancer, respectfully. 6. Discussion There are limited basic health services which preclude prevention efforts and facilities for diagnosis and treatment of cancer in the Solomon Islands. As of today, the Cancer Registry in the Solomon Islands consists of the NRH cancer registry which is a hospital based registry and pathology tumour registry, it remains nominally a national cancer registry but in actuality only reflects cancers diagnosed and treated at the NRH. Preventative measures aimed at risk factors for developing cancer, including HPV infection, betel quid chew and infection of chronic hepatitis, are under developed and not widespread. New campaigns exist aimed at uptake of Pap smears and HPV vaccination. For cervical cancer, it is not fully clear what screening practices clinicians actually use, which patients seek preventative care and what the options are for follow-up. Our team will be investigating these questions in future research arranged to occur in June-Sept 2017. In terms of GI cancer, the partnership between Solomon Island, Australian and Americans demonstrates the importance of diagnosis and then intervention ranging from palliation to curative operative resections of gastric and colorectal tumors. An audit of health system demonstrates poor access to any health care, due to geographical barriers and economic fragility and underscores importance of prevention of cancer at the primary care level. 7. Limitations The data from the cancer registry are not national or representative and likely contain some misdiagnosis and certainly misses cases due to the fact that many are clinically diagnosed cases, specifically, it is highly likely that lung cancers are underrepresented in the data presented from the cancer registry as currently the ability to retrieve a specimen for lung histology does not exist. These data do however represent a good indication of the number and type of cancer cases at the NRH. There also remains a gap in representation for palliation only cases as they are often not recorded. Nurses endure a significant burden for keeping the cancer registry up to date and limited technological support and equipment remain significant challenges. It is the hope with the new computer and the employment of a medical officer next year, the management and recording of data in the cancer registry will improve.

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8. Recommendations Recommendations for the Solomon Islands with respect to cancer are presented by summarizing existing regional recommendations, as well as local recommendations. In terms of regional recommendations, Pacific leaders have prepared an NCD Roadmap Report. This report provides the best available international evidence for effective, feasible, and “best buy” strategies to address NCDs, including cancer. At a 2014 meeting, the Pacific Island Countries jointly agreed on strategic action areas. Those related to cancer are outlined here:  Increase excise duties to 70% of the retail price of cigarettes over the medium term.  Consider a tax increase for alcohol products to reduce harmful alcohol consumption.  Strengthen the evidence base to enable better investment planning and program effectiveness, thereby ensuring that interventions work as intended and provide value for money.  Share lessons across Pacific Island Countries regarding the Package of Essential NCD interventions (PEN) [35].  Strengthen prevention of NCDs in primary care to relieve pressure on hospitals.  Implement tobacco control policies, particularly with domestic loose-leaf tobacco producers [34]. Local recommendations gathered for this manuscript include: establishing an oncology unit within the NRH to accommodate at least 4 cancer patients receiving chemotherapy and supports in place to assist patients to “faithfully attend all the cycles as per treatment regimen” and ensure that treatment decisions regarding chemotherapy can be made by non-surgical specialties, establish culturally-supported palliative care, develop a local histopathology service as tissue samples are currently sent overseas to Brisbane, Australia. This lack of available histopathology results in clinicians being particularly judicious in obtaining biopsies, as delays in treatment initiation or complete loss to follow-up are common. There is also a need for improved training for primary healthcare providers in recognizing the presenting features of cancer, as well as further training in oncology and oncology drug supply locally in particular for palliation. Recommendations have also been made regarding the cancer registry. The Solomon Islands is a fragile state with a recent history of political unrest and natural disasters which occur frequently. These can and often lead to loss of infrastructure (eg medical records room), hardware access, data input frequency and quality. A step towards information fidelity might be achieved by using more mobile devices which might be less vulnerable to physical damage during natural disasters due to their portability and small size. Having a financially supported space in the digital cloud for information storage would be useful. Alternatively, linkage or “twinning” with an overseas health information center could offer longer term data management and personnel upskilling; provided this is well coordinated with local, regional and global health partners. Additionally, the following are recommendations regarding the NRH cancer registry  clarify the aim of the registry and determine activities desired by the staff in the unit in order to increase the quality of supervision and outputs,  design/write-up a job description for the staff in this unit to guide their practice (level of education/training, ethics),  embed this cancer registry into both the clinical and administration levels in order to ensure it is prioritised and sustained

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 upgrade to the CanReg5 database and increase skill in entering and summarising and sharing data within and outside of the Solomon Islands,  measurement of survival by following up patients would also be very beneficial,  participate in IARC regional hubs to obtain training and technical assistance and use IARC and the International Association of Cancer Registries’ free tools, and training,  Other specific changes could include: staff exchanges between Solomon Islands and neighbouring Australia, routine quality control in line with IARC conventions, data checks using existing IARC programs to do this, improving data capture from outlying hospitals and aid posts. Obtaining good-quality data is only a starting point—there must also be the capacity to make use of such data, and health-care resources need to be efficiently allocated. The improvements and future expansion of the Solomon Island cancer registry will ideally encourage investment to build capacity in oncology, and ultimately help to ensure that high-quality evidence is used to guide the allocation of health-care resources to where they are most needed [36]. We recommend that the Solomon Islands establish a local cancer advisory group to help assist with decision making. WHO recommends the allocation of scarce resources to primary prevention (WHO Efficient Use of Resources) yet new data suggests that at least one Pacific Island country allocates around one-third of its total national health budget on overseas treatment referrals for 100 patients [12]. A local advisory group may help advise, direct funds, develop decision-tools and assess opportunities to improve care, prevent resource misallocation and avoid unethical situations. We also recommend improvements to palliative care. Solomon Islands could aim for improved education and clinical support of palliative patients and to ensure national access to fifteen medications as identified by the WHO and International Association for Hospice and Palliative Care as essential treatments for the most common symptoms experienced by palliative paitents [37]. These symptoms include anorexia, anxiety, constipation, delirium, depression, diarrhea, dyspnea, fatigue, nausea and vomiting, pain, and respiratory tract secretions [37]. Of course there are broader strategies for increasing the effectiveness and equity of health expenditure in the Pacific, including improving financial management, health worker supervision and management, and improving the quality and effectiveness of diagnostic and clinical services [11]. There is a need to support health systems and service strengthening overall in the Solomon Islands – which will underpin the support of cancer prevention, detection, diagnosis, treatment and palliation. A strong focus on strengthening primary care will go a long way to supporting this. This includes improvement in vital statistics such as births and deaths through the new Solomon Island Electronic Civil Registration. According to an assessment carried out by UNICEF in 2007, the Solomon Islands is estimated to be the lowest in the Pacific with approximately 0.1% of all births formally registered in 2007 [38]. 9. Conclusion Cancer strains an already burdened health system. It is important for future initiatives to determine the epidemiology of cancers in the Solomon Islands to ensure a major emphasis on prevention of at least some cancers, and early detection of others. Epidemiological investigation, can improve decision-making and strategic plans. Partnerships within the Solomon Islands as well as internationally are likely to be a useful tool to improve

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cancer prevention and care, as well as potentially improve local health professional’s job satisfaction and reduce brain drain. The Solomon Islands continues to experience challenging circumstances in diagnosing, treating and palliating cancer. Key stakeholders recommend establishing specialty expertise (in the form of a cancer unit), improved registry processes and increased collaboration between the sole tertiary hospital nationwide and other health services as important targets for incremental improvement. Authorship contribution statement Martiniuk: received the invitation to submit, gathered the coauthorship team, set the methods and plan for the work, drafted the first manuscript and made final edits to the submitted final paper Jagilli: gathered data on cancers in the Solomon Islands, wrote the sections on cancer in 2014 and 2015 including the data tables and recommendations for improvements, approved the final manuscript Natuzzi: gathered and wrote the gastrointestinal cancer section, and the NRH health system audit section, approved the final manuscript Ilopitu: National Referral Hospital, cancer registry nurse, Honiara, collected the cancer registry data and approved the final manuscript Oipata: National Referral Hospital, cancer registry nurse, Honiara, collected the cancer registry data and approved the final manuscript Christie: travelled to the Solomon Islands from Australia to collect the data and write the paper sections on the health system audit of a provincial hospital and the case vignettes, and approved the final manuscript Korini: wrote the section about the health system audit of the provincial hospital and wrote recommendations and approved the final manuscript Vujovich-Dunn: wrote the cancer risk factors and assisted with writing all other sections of the manuscript, and approved the final manuscript Yu: drafted the initial manuscript with Martiniuk, cleaned the existing descriptive analyses from the NRH cancer registry and created Table 1, and approved the final manuscript Conflicts of interest The authors have no conflicts to declare. Funding No specific funding was used for this research. Martiniuk was funded by an NHMRC TRIP Fellowship. Acknowledgements Thanks also to: Dr Jared Liligeto and Chris Leve in the Solomon Islands who helped to complete the modified SARA health system audit tool and thank you to Sophia Hil (medical student in Australia) for her knowledge regarding cervical cancer and screening in the Solomon Islands. Alexandra Martiniuk is funded by an Australian National Health and Medical Research Council (NHMRC) Translating Research into Practice (TRIP) Fellowship.

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