PERSPECTIVE ARTICLE
Jennifer Soh and Joo Ha Hwang, M.D., Ph.D.
Citation: Journal of Asian Health. 2021;2:e202102
Copyright: © 2021 Journal of Asian Health, Inc. is published for open access under the license Creative Commons CC BY-NC 4.0 License. Authors have full copyright.
Published: July 12, 2021
Correspondence to: Joo Ha Hwang. Email: jooha@stanford.edu
Case History: By Jennifer Soh
I found myself sitting across from my 73-year-old grandfather at a restaurant in Berkeley, California, watching him struggle to finish his food. He had once fought in the frontlines of the Vietnam War, but now he looked shriveled and limp, staring at his plate as if it was the worst enemy he had ever faced. It took him minutes to muster up the courage to take another bite, and while he chewed and chewed, I could see the defeat in his eyes. Before he even tried to swallow, he leaned down and swiftly spat out his food.
He had been assured by several doctors in the earlier months that his symptoms were a normal sign of aging. But as his nausea, heartburn, and inability to swallow grew worse, his condition was no longer dismissible. Tests were ordered, and a diagnosis was quickly made. My grandfather had been living with stage II gastric cancer.
We later learned that gastric cancer disproportionately affects East Asian populations who are at high-risk for helicobacter pylori infection, likely due to their high-sodium diets and common alcohol and tobacco usage.1 So as a 73-year-old Korean man with a previous history of smoking, my grandfather found himself at the highest known risk for gastric cancer possible. Yet not one of the three doctors who were consulted with his case even mentioned cancer as being a possibility for his pain.
My grandfather’s story is not an anomaly. In fact, his experience is shared by thousands of East Asian American families, who live unaware of gastric cancer and are seldom informed by their physicians about their risk.
My grandfather shortly returned to Korea after his diagnosis to seek treatment and is now in remission. But as I reflect on his experience, I feel frustrated. My family had to learn of our risk for gastric cancer through my grandfather’s diagnosis. Here in the United States, my parents must regularly advocate for themselves at doctor’s appointments, an experience that most minorities relate to. I watch as they constantly check for any symptoms that may indicate early signs of cancer, second guessing if their indigestion is only temporary or a signal—a never-ending state of paranoia that my sister and I, and thousands of other East Asian Americans, must continue to live through if change is not implemented soon.
The case history by Jennifer Soh eloquently tells the unfortunate story of her grandfather being diagnosed with gastric cancer and why this could have been prevented or had a much better outcome. Although gastric cancer is uncommon in the United States (26,560 estimated new cases in 2021), it is actually more common than esophageal cancer (19,260 estimated new cases in 2021), where screening guidelines in the United States exist.2 The majority of patients who develop esophageal cancer in the United States are White men with a reflux disease, whereas a significant proportion of patients who develop gastric cancer are Asians with a history of helicobacter pylori infection. If Jennifer’s grandfather had been residing in Korea, he would have received gastric cancer screening with an endoscopy beginning at the age of 40 and would have had an endoscopy every 2 years according to national cancer screening guidelines.3 Under this scenario, Jennifer’s grandfather would have been either diagnosed with high-grade dysplasia (pre-cancer) or early gastric cancer that likely would have been cured with a procedure called endoscopic submucosal dissection (ESD), which is an endoscopic procedure to resect early gastric cancer that preserves the entire stomach and avoids invasive surgery.
The overall 5-year survival rate for gastric cancer in the United States is 32% compared with 67-69% in Korea and Japan.4 This difference is largely attributed to the differences in stage of disease that gastric cancer is diagnosed. In the United States, a majority of gastric cancer is diagnosed as advanced disease (stages III and IV) where surgery and chemotherapy are the primary modalities for treatment and is often for palliative purposes only with no real chance for long-term survival or cure. In Korea and Japan, a majority of cancers are diagnosed when the disease is still limited to the lining of the stomach (mucosa), where it can be resected by ESD, typically resulting in curative resection with 5-year survival rates of over 95%.
In order to improve gastric cancer survival in the United States, we need to diagnose gastric cancer at an earlier stage, which can be accomplished by screening and surveying those who are at high risk for gastric cancer. Fortunately, we clearly know the risk factors for gastric cancer in the United States. The highest risk groups in the United States are immigrants from high incident regions such as East Asia, parts of Eastern Europe, and the west coast of South America.5 There is actually a recommendation by the American Society for Gastrointestinal Endoscopy that suggests that immigrants from high incidence regions have endoscopy for gastric cancer screening; however, most general internists and gastroenterologists are not aware of this suggestion.6 Therefore, we need to educate more those who are at high risk and physicians who care for these patients.
Gastric cancer is curable if diagnosed at an early stage, and mortality from gastric cancer is preventable. However, since symptoms typically present when the cancer is at a later stage, screening and surveillance of patients who are at high risk is the only way to reduce mortality rate for this disease. Gastric cancer is not uncommon in the United States – we know who is at high risk, and we know that early diagnosis improves survival. We need guidelines from national societies, and ideally from the United States Preventative Services Task Force (USPSTF), to recommend gastric cancer screening for those who are at high risk in the United States, with the largest group being immigrants from East Asia.
Jennifer Soh would like to acknowledge Dr. Bryant Lin, Co-Director of the Center for Asian Health Research and Education at Stanford University, Dr. Warren Suh, Medical Director at the Ridley Tree Cancer Center in Santa Barbara, CA, and Dr. Joo Ha Hwang, Professor of Medicine in the Division of Gastroenterology and Hepatology at Stanford University and the Chair of the Asian American Stomach Cancer Disparity Task Force, for their insight and support to make this piece possible.