How Healthy Are We, Really?
With rising cancer and diabetes rates and the myriad diseases prevalent among Native Hawaiians and those in underserved communities, Hawai‘i isn’t the model of health it’s touted to be.
IN RANKINGS OF THE HEALTHIEST STATES…
…Hawai‘i often comes out on top, or close to it. Year after year, surveys and reports suggest that our state’s residents are more active than their counterparts on the continent, breathe cleaner air, are happier and live longer.
But that’s far from the full story.
Tucked behind those rosy statistics, doctors say, are rising rates of cancer among patients under 50, genetic links to cancer that affect many Island residents, worrisome increases in obesity and such chronic diseases as diabetes, and persistent gaps in health care for communities that need the most help.
Younger Cancer Patients
The state’s medical community is scrambling to understand what’s driving the rise in cancer rates among younger, preretirement-age people. From 2000 to 2021, breast cancer among Asian and Pacific Islander women under 50 soared, from 36 to 55 cases per 100,000 patients, according to the National Cancer Institute. Oncologists also are seeing more people under 50 with colon, pancreatic and lung cancers, and it’s not clear why.
It’s “really very worrisome,” Dr. Jennifer Carney, Hawai‘i Permanente Medical Group’s chief of hematology and oncology, says of the rise in early onset cancers. “Some of these patients aren’t even in the screening age groups yet.”
In fact, screening recommendations have changed to address the situation. Colonoscopies are now recommended for people starting at age 45, rather than 50. A woman with an average breast cancer risk should get a mammogram every other year starting at 40, also earlier than previous guidelines.
Patients in their 30s and 40s who are grappling with serious cancers often have different concerns than those in their 60s and 70s, Carney says. Younger patients, she says, might have school-age children or be concerned about fertility, and they’re probably still working, whereas older patients are more likely to be retired.
Oncologists also are seeing more people under 50 with colon, pancreatic and lung cancers, and it’s not clear why.
Genetic Links
Along with younger oncology patients, doctors say genetic factors are increasingly being linked to malignant growths. For example, liver and gastric cancers tend to be more prevalent among Asians, while Native Hawaiians are at higher risk for several cancers and are more likely to present with more progressed disease. “Part of this is the social determinants of health,” Carney says. “There is also something biological.”
The leading cause of cancer deaths nationwide is lung cancer, and in the Islands, Dr. Ayman Abdul-Ghani says he and other doctors see more of it among nonsmokers than the national average, typically among Asian women. Lung cancer rates are also higher among Native Hawaiian women.
“Often, the cancer is found when patients go in for something else,” says Abdul-Ghani, a thoracic surgeon at Hawai‘i Pacific Health. “I’ve seen patients who go for shoulder X-rays or computerized tomography scans for their neck or abdomen, and the doctors find lung cancer in the part of the chest covered in the scan.”
Native Hawaiians also have a 60% higher chance of developing pancreatic cancer than others, says Queen’s Health Systems oncologist Dr. Jared Acoba. “If you have a Native Hawaiian male who has two risk factors, say who smokes and has one family member with pancreatic cancer, his risk of pancreatic cancer is five times the population.”
While genetics can’t always accurately predict the future, genetic counseling can encourage patients to seek regular screenings to catch cancers earlier.
Trying to Outsmart Cancer
Fortunately, the medical community’s arsenal to fight cancers is growing. In addition to traditional treatments, doctors are using targeted therapy to go after the DNA mutations fueling malignant growths and deploying immunotherapy drugs to stimulate a patient’s own immune system. They’re also using genetic counseling to target higher risk patients. At Kaiser Permanente, for example, some cancer survivors and patients with family histories of certain variations of the disease qualify for genetic testing to assess their risk.
While genetics can’t always accurately predict the future, genetic counseling can encourage patients to seek regular screenings to catch cancers earlier, says Rebecca Yee Bassett, Kaiser Permanente Genetic Counseling section chief. “Family history can be really critical for people to be aware of,” she says, noting that genetic counseling likely will be more readily available in the near-term. “This is precision medicine, where we use our genetic information to help guide doctors and treatments. It’s the ultimate in individualized health care.”
Nearly six years ago, Olena Heu, a former local TV news anchor who now runs her own marketing firm, underwent a preventive double mastectomy after genetic testing predicted an increased breast cancer risk. Heu’s grandmother had breast cancer, and her mother and aunt both died of the disease.
In 2019, a year after her mother’s passing, the 44-year-old decided to remove both breasts to reduce her risks, and opted out of reconstructive surgery because implants pose risks of their own and would have required additional recuperation.
“I think it might have been one of the best medical decisions in my life,” says Heu, who documented her journey via YouTube videos that reached people around the globe.
“It really empowers me to go forward and do all the things I want to do and not have to be worried. Because of science and preventative care, we can make these decisions that will essentially help prolong our lives. We live in a time where we’re given those opportunities.”
Addressing Inequalities in Care Is Key
While advances in screening and cutting-edge treatments are giving doctors new tools in fighting disease and giving patients better long-term prognoses, socioeconomic inequalities continue to drive health disparities among Native Hawaiian and Pacific Islander populations. In many rural and remote areas of the state, for instance, there’s a lack of health care providers, and it’s these residents often hit hardest by Hawai‘i’s rising cost of living.
“Multiple family members are working two or three jobs to afford the high cost of making ends meet. It’s really hard to exercise, be healthy if you’re always busy and stressed,” says Dr. Jennifer Loh, chief of endocrinology at Hawai‘i Permanente Medical Group. “It’s a lot more expensive to eat healthy as well.”
To address inequalities in cancer care, including preventive screenings, the John A. Burns School of Medicine recently partnered with the University of Hawai‘i Cancer Center and Hawai‘i Cancer Consortium members, who represent several top medical groups. The effort, called Ka ‘Umeke Lama, or “Bowl of Enlightenment,” aims to “erase disparities in cancer outcomes” in the Islands by advancing cancer education, deploying oncology providers and early cancer detection units to rural and underserved communities, launching targeted clinical research trials and developing telehealth systems.
The group has its work cut out. Across the state, Native Hawaiians have historically had the highest mortality rates for all types of cancers compared to white residents. Pacific Islanders are also far more likely to be diagnosed with some cancers.
Ka ‘Umeke Lama is aimed at developing a “strong and integrated oncology infrastructure” in Hawai‘i and the Pacific, says Dr. Naoto Ueno, director of the UH Cancer Center. He believes cancer care should be equitable and rooted in both innovation and cultural understanding. “Everyone should have access to high-quality cancer care,” he says.
Over the past decade, the prevalence of Type 2 diabetes in Hawai‘i has increased by more than 50%.
Type 2 Diabetes on the Rise in Hawai‘i
When it comes to health disparities, though, cancer isn’t the only concern.
Over the past decade, the prevalence of Type 2 diabetes in Hawai‘i has increased by more than 50%. Today, more than 11% of the population—or about 150,000 people—have Type 2 diabetes and 40% are living with pre-diabetes. The most common causes of Type 2 diabetes in adults are a poor diet, a sedentary lifestyle and high stress.
When diabetes is untreated or poorly treated, it can lead to a host of other chronic conditions, including heart and kidney disease, nerve damage, mobility problems, and even depression and dementia. Like with other chronic conditions, Native Hawaiians and Pacific Islanders are at higher risk of developing diabetes—2.5 times higher compared to the overall population—the Office of Minority Health reports.
They’re also at greater risk of dying from heart disease, the state’s top killer. New research from the American Heart Association shows Native Hawaiians and Pacific Islanders have far higher death rates from heart disease than Asian Americans, and the second highest among all ethnicities, races and other groups behind only Blacks.
Obesity in Local Children a “Significant” Problem
Alarmingly, Hawai‘i doctors are also seeing rising rates of obesity among children—and more cases of Type 2 diabetes, too. The National Institutes of Health has called childhood obesity in Hawai‘i a “significant” problem, with some communities seeing rates of 40% or more. Overall, a third of all Hawai‘i keiki are overweight or obese.
“Before, we would rarely see Type 2 diabetes in children,” Loh says. Now, doctors nationally are finding about 18 cases per 100,000 children, the latest federal data shows, with the highest rates among Blacks, Latinos and Pacific Islanders.
Dr. Nadine Tenn Salle, chief of pediatrics for The Queen’s Health Systems, says chronic conditions in childhood must be dealt with holistically. Kids aren’t put on diets, she says, but are encouraged to try healthier foods and activities.
Cultural competency is key, too.
Dr. Leimomi Kanagusuku, president of the Hawai‘i Academy of Family Physicians, grew up in Wai‘anae and is part Native Hawaiian. She thinks of health as an “intricate web” of factors and tells her patients so. Genes aren’t the only thing that determine health outcomes— daily habits and environment count too, she says. As a family medicine physician with Hawai‘i Pacific Health, Kanagusuku says her patients want to be healthier but need resources and guidance. “Instead of telling patients to eat healthy, you ask them about their day and who cooks.”
By tapping into specifics, she offers actionable advice. “So much of health has to do with our surroundings. Native Hawaiians have lower socioeconomic status, more asthma, more cancer, more alcohol use, higher rates of mental health issues.”
Untangling it all to help patients is both daunting and rewarding. She recalls one of her younger patients with diabetes and extremely high blood sugar. He didn’t want to go on medication, so Kanagusuku had “some very real conversations” with him about turning his life around. He did, even getting his blood sugar levels below the goal.
What About So-Called Wonder Drugs?
For Loh, the endocrinologist, “game-changer” drugs like Ozempic are powerful but not the only answer. “It has certainly been impressive” to see the success of Ozempic and similar drugs, she says. “But we don’t know the long-term effects.”
The class of drugs that includes Ozempic works by mimicking a hormone to make you feel full faster and likely requires long-term usage. “It’s not a one-size-fits-all,” she says. “But it can play a part in your weight-loss journey.”
Another part might be monitoring your blood sugar if you have prediabetes. Over-the-counter blood glucose monitors can quickly show patients how food choices, like sweets or rice, impact their blood sugar and how they feel throughout the day. “Some people find it very enlightening,” she says. “That can be empowering.”
