It took more than a decade after Xerxes Camacho stopped chewing betel nut for oral cancer to manifest itself.
The Rota resident thought he had left the habit behind for good when he quit cold turkey in 2013. But in 2025, what initially appeared to be an ordinary sore inside his cheek turned out to be Stage 4 oral cancer, setting off a painful battle that would take him from Rota to Saipan and eventually Los Angeles for surgery, chemotherapy, and radiation.
For Camacho, the diagnosis was especially difficult to accept because he had already spent years trying to free himself from a habit he picked up as a teenager.
Cancer was also no stranger to his family. His wife had also battled breast cancer, making his diagnosis another difficult chapter in the couple's experience with the disease.
Camacho, a specialist with the CNMI Department of Commerce, said he first noticed something unusual while having dinner with his wife. Rice had become lodged between his teeth, and while trying to remove it with his finger, he accidentally poked the inside of his cheek.
He initially dismissed the resulting sore because he had experienced mouth sores before. This time, however, it refused to heal.
After two weeks, the sore began changing shape. Eating became difficult, talking became painful, and his attempts to clean and treat the affected area did little to improve his condition.
Camacho eventually consulted Dr. Savino on Rota, who performed a biopsy. The results confirmed cancer.
He was immediately referred to Saipan, where doctors performed another procedure to remove the affected tissue. But subsequent tests revealed a positive surgical margin, meaning cancer cells remained at the edge of the removed tissue.
Further treatment in Los Angeles became necessary.
What made the diagnosis particularly shocking was that Camacho had shown no obvious symptoms before discovering the sore.
An outdoorsman who enjoyed hunting, fishing, and other physical activities, he said he had not experienced unusual fatigue or other warning signs.
His family was equally stunned, particularly because he had not chewed betel nut since 2013.
"I was really shocked," he recalled.
Camacho believes his former betel nut habit contributed to his illness, although he cannot say exactly when the cancer began developing. The cheek injury was how he first noticed the persistent sore, not evidence that the injury caused the cancer.
His relationship with betel nut began in 2000, when he entered high school.
He said peer pressure initially drew him into chewing. He did not enjoy it the first time, but after trying it again, the habit gradually took hold.
What started as an experiment became an addiction that followed him throughout high school and into adulthood.
At his worst, Camacho was chewing as many as 10 times a day, from the moment he woke up to before and after meals and during his leisure time.
His preferred mixture consisted of betel nut, lime, and cigarette tobacco, sometimes with betel leaf.
Chewing became so deeply ingrained in his routine that he sometimes prioritized it over eating. He relied on the sensation and relaxation it provided and found it difficult to concentrate without it.
"I would choose it over eating," he recalled.
Camacho tried quitting twice over the years, managing to stop for periods before eventually returning to the habit.
He missed the taste, the sensation, and what he described as the kick that chewing provided.
Each attempt to quit disrupted his daily routine, but the temptation eventually proved too difficult to resist.
The turning point came in 2013, when he visited a dentist for a tooth extraction.
The dentist noticed white patches inside his mouth and declined to proceed with the extraction, warning him that continued chewing could eventually lead to cancer.
That warning convinced Camacho to abandon the habit completely.
"I just quit everything," he said.
For Camacho, gradually reducing his consumption was never going to work. He knew that even occasional chewing could pull him back into the habit.
He threw away his chewing supplies and resolved never to touch betel nut again.
It was a difficult process, but he succeeded.
For more than a decade, Camacho stayed away from chewing. He continued working, enjoyed outdoor activities, and believed the health risks associated with his former habit were behind him.
Then came the cancer diagnosis.
In Los Angeles, Camacho underwent a complicated reconstructive operation lasting approximately 10 to 12 hours.
Surgeons removed the cancerous tissue from his cheek and reconstructed the affected area using tissue and blood vessels taken from his arm. They then used skin from his leg to cover the donor site on his arm.
Doctors also discovered that the cancer had spread to lymph nodes in his neck, requiring additional surgery. Camacho recalled that approximately 60 lymph nodes were examined.
Following the operation, he spent time in intensive care before being transferred to a recovery room.
For several days, he was fed through a tube inserted through his nose because doctors wanted to protect the surgical area while it healed.
The surgery was only the beginning.
Camacho subsequently underwent six weeks of chemotherapy and radiation, treatments that brought nausea, constipation, exhaustion, painful mouth sores, skin burns, and difficulty eating.
By the third week, the side effects had become increasingly difficult to endure.
His skin burned from the radiation, while painful sores inside his mouth made eating almost unbearable.
He also experienced a metallic taste, dry mouth, loss of appetite, and exhaustion.
Doctors had warned him that the treatment would be painful, but experiencing it firsthand was another matter.
His recovery has been gradual, and even today, the effects remain.
Dry mouth continues to make eating difficult. He also struggles to open his mouth fully because of scar tissue left by the surgery.
Foods he once enjoyed, particularly tougher meats and barbecue, are now difficult to eat. Instead, he often turns to oatmeal, mashed potatoes with gravy, yogurt, and other soft foods.
Even ordinary meals require adjustments, including cutting food into smaller pieces.
Speaking has become another challenge.
Because part of his lip no longer closes the way it once did, Camacho sometimes struggles to pronounce certain sounds, particularly words involving the letters P and V.
He frequently finds himself repeating words so others can understand him.
"I'm still relearning how to speak," he said.
The treatment also changed his appearance, leaving scars on his arm, leg, neck, and face.
Although some of the swelling and skin discoloration have subsided, he continues to perform jaw exercises to improve his ability to open his mouth.
Camacho said the financial burden of seeking treatment thousands of miles from home presented another challenge.
Although Medicaid and Aetna helped cover his medical care, housing and transportation expenses were another matter.
Family members and friends organized a fundraiser to help pay for his stay in Los Angeles. Relatives in California also opened their home to him while he recovered from surgery and prepared for additional treatment.
He remains grateful for the support that made his treatment possible.
But perhaps the most troubling part of his experience was discovering that he was far from the only Northern Marianas resident battling oral cancer.
During his stay in Los Angeles, Camacho recalled encountering approximately 11 patients from the CNMI seeking treatment for the same disease.
Some were arriving while others were preparing to return home. He also heard about additional patients awaiting treatment.
The experience opened his eyes to what he considers a serious health problem confronting the islands.
His account is particularly relevant in the Northern Mariana Islands, where betel nut chewing remains a familiar social practice despite its established association with oral cancer.
The World Health Organization's International Agency for Research on Cancer has classified areca nut, commonly known as betel nut, as carcinogenic to humans. The cancer risk is not limited to mixtures containing tobacco.
For someone who spent 13 years chewing betel nut before finally giving it up, Camacho knows that quitting is easier said than done.
But having endured major surgery, weeks of cancer treatment, and the lasting physical consequences, he hopes his experience will convince others to reconsider the habit before they face a similar ordeal.
He also encourages residents to seek medical attention whenever they notice unusual or persistent changes inside their mouths rather than waiting for symptoms to become severe.
"Early detection can save lives and give you a chance to tackle it early on," he said.
His strongest message, however, is directed at young people who may be tempted to begin chewing because of friends or social pressure, just as he did more than two decades ago.
"To the youth, my message is simply this: It's okay to say no," Camacho said.
"It's not worth it."
For Camacho, the scars are reminders not only of what he endured but also of the second chance he has been given.
"You get one life," he said. "Protect your health, protect your peace, and protect your future."
Having experienced the disease firsthand, he hopes his testimony will encourage people to abandon chewing and seek early screening when something does not seem right.
"It is only by the grace of God that I am very grateful to wake up today," he said, expressing hope that sharing his scars will bring greater awareness of oral cancer.
This reporting has been supported by the National Press Club Journalism Institute Public Health Reporting Fellowship, funded by the Common Health Coalition.
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