Oral cancer crisis in CNMI comes under closer scrutiny

Oral cavity and pharyngeal cancer ranked second among reported cancers in the CNMI from 2007 to 2022, with nearly six in 10 cases diagnosed at an advanced stage, according to the latest comprehensive cancer registry obtained by Marianas Press.

University of Guam Cancer Research Center researcher Yvette Paulino said the link between betel nut chewing and oral cancer has been established for decades, but combining betel nut with tobacco and alcohol can multiply the risk of developing the disease.

The findings underscore a serious public health concern in the Commonwealth, where more than one in five adults chew betel nut, most chewers add tobacco, and fewer than half of adults reported visiting a dentist in the preceding year.

These concerns have prompted Marianas Press to launch a series examining oral cancer, its connection to betel nut chewing, the difficulties of early detection, and the challenges faced by patients seeking treatment.

Subsequent reports will feature Commonwealth Healthcare Corp. oncologist Dr. Peter Brett, oral cancer survivor Claudine Atalig, and Commonwealth Cancer Association executive director Lynn F. Tenorio. Brett will discuss the challenges of treating oral cancer patients, while Atalig will share her experience battling the disease. Tenorio will discuss CCA's efforts to curb betel nut chewing and its awareness, prevention, and outreach campaigns aimed at reducing oral cancer and other cancers in the Commonwealth.

The Pacific Regional Central Cancer Registry's Cancer in the U.S. Affiliated Pacific Islands 2007–2022, updated in April 2025, recorded 734 cancer cases in the CNMI during the 16-year period.

Breast cancer ranked first with 133 cases, followed by tobacco-related oral cavity and pharyngeal cancer with 109, colorectal cancer with 79, and lung and bronchus cancer with 70.

Of the 109 oral cavity and pharyngeal cancer cases, 59% were diagnosed at Stage 3 or higher.

The figures reflect reported diagnoses rather than the number of people currently living with cancer. The registry also does not establish how many cases resulted specifically from betel nut chewing.

Meanwhile, the Commonwealth Healthcare Corp.'s 2023 CNMI Non-Communicable Disease and Risk Factor Adult Hybrid Survey, involving 1,770 adults, found that 22.5% had chewed betel nut within the previous 30 days.

Among current chewers, 72.4% chewed daily, while 93.1% added tobacco. The average age at which current daily chewers began chewing was 17.

The survey also found that 68.5% of current chewers wanted to quit, while 56.8% had attempted to stop for at least one day during the preceding year.

Only 47.5% of adults reported visiting a dentist within the preceding year, raising concerns about missed opportunities to identify suspicious changes in the mouth.

The cancer registry covers diagnoses only through 2022, while the risk-factor survey reflects conditions in 2023. Although these are the latest comprehensive studies obtained by Marianas Press, they leave unanswered questions about the current extent of oral cancer and betel nut chewing in the Commonwealth.

In a Zoom interview with Marianas Press, Paulino said studies linking betel nut to oral cancer date back to the late 1980s, with the International Agency for Research on Cancer documenting the connection in its 2004 Monograph 85.

Despite decades of international research, she said the Marianas still lacks long-term studies establishing the precise cancer risks faced by local betel nut chewers.

Paulino explained that researchers would ideally conduct a cohort study, following participants over many years to determine how exposure to betel nut affects their likelihood of developing oral cancer.

"Because we don't have this, we don't have the risk data for the Marianas, but we have risk data on other populations across the world who have generated long-term data on betel nut chewing and oral cancer risk," she said.

Such studies require substantial funding and sustained monitoring, sometimes lasting decades.

Paulino stressed, however, that the absence of Marianas-specific studies does not diminish the international evidence establishing betel nut as carcinogenic, even without tobacco.

She said cigarette smoking, smokeless tobacco, alcohol consumption, and betel nut chewing each carry independent cancer risks. Combining them can produce an effect greater than the sum of their individual risks.

"Studies have demonstrated a synergistic, meaning a multiplicative, effect," she said.

The amount of betel nut consumed, duration of each chewing session, time the nut remains in the mouth, and number of years a person chews also influence cancer risk.

"There is definitely a dose-response relationship, very similar to smoking," Paulino said.

Early detection presents another challenge.

Paulino said regular dental examinations can help identify abnormal changes in the mouth, including white or red lesions that may indicate precancerous conditions.

She also pointed to oral submucous fibrosis, a condition associated with betel nut chewing that causes tissues inside the mouth to harden over time.

Although she is not a clinician, Paulino said dental professionals play an important role in recognizing these changes and encouraging patients to seek further evaluation.

In an October 2025 interview with Marianas Press, Commonwealth Healthcare Corp. chief dentist Dr. Angelica Sabino similarly emphasized the importance of oral cancer screening, saying residents could request free examinations through participating dental clinics on Saipan.

Sabino said the screening focuses on the soft tissues inside the mouth rather than the condition of a patient's teeth and generally takes about five minutes.

She also advised residents to seek examination for mouth sores or lesions that do not disappear within two weeks.

Sabino said the number of oral cancer patients encountered at the hospital fluctuated, making it difficult to establish a consistent monthly pattern from her observations.

Paulino acknowledged that the Marianas lacks systematic data on how effectively oral cancer is being detected early. She recalled anecdotal cases in which dentists identified abnormal tissue changes and encouraged patients to stop chewing, but said such experiences cannot substitute for comprehensive local research.

Another concern, Paulino said, is addressing the dangers of betel nut without stigmatizing communities where chewing has longstanding cultural significance.

She distinguished traditional ceremonial uses from the commercialization of betel nut, which has helped transformed an occasional cultural practice into a widespread habit.

Historically, she said, betel nut was associated with celebrations, rites of passage, and other cultural occasions rather than necessarily being consumed frequently or in large quantities.

"What we're really seeing is like the commercialization of this cultural practice that really has now become a health problem," she said.

Paulino said prevention should begin with educating children before they develop the habit, followed by consistent messages as they grow older.

For existing chewers, she emphasized the importance of cessation assistance and regular dental examinations.

She also welcomed the CNMI's oral cancer screening initiatives and betel nut labeling measures, saying the Commonwealth has an opportunity to evaluate whether these efforts are changing behavior.

Paulino said public health programs should be measured over time, particularly their impact on chewing prevalence among young people and adults.

She also called for greater cooperation among the Commonwealth Cancer Association, Commonwealth Healthcare Corp., dental professionals, researchers, and community organizations.

"It's a team effort. It's going to take the community," she said.

While the cancer registry documents cases diagnosed through 2022 and the 2023 survey provides a snapshot of chewing habits, neither establishes the Commonwealth's current oral cancer burden or how many cases are directly attributable to betel nut.

The outdated figures underscore the need for more timely cancer surveillance, locally focused research, and sustained prevention efforts.

For now, the available evidence presents a troubling picture: oral cavity and pharyngeal cancer accounted for 109 reported cases over 16 years, most were diagnosed at an advanced stage, and betel nut chewing remains common among CNMI adults.

This reporting has been supported by the National Press Club Journalism Institute Public Health Reporting Fellowship, funded by the Common Health Coalition.