had given him an opportunity to work. In 1981, Aki was
born. Tsuruoka continued to work with cameras, including
running his own business doing repair work mandated by
camera warranties, until he retired in 2003.
English is Tsuruoka’s second language, after Japanese, and
he often worked with Japanese clients during his career, he
says, so he doesn’t feel entirely comfortable speaking English.
Partly because of this, after Tsuruoka’s stomach cancer
diagnosis, Smith took on the task of scheduling appointments,
accompanying him to appointments, researching treatment
options and keeping tabs on medical bills. At first, it seemed like
every time the pair went to a new appointment, they left with a
different treatment plan. There was uncertainty about the stage
of Tsuruoka’s cancer. Doctors told him he would need to have his
stomach removed, but he felt that he wasn’t getting a good explanation of how he could live without a stomach.
“My dad was so scared,” Smith says. “I was scared too. It didn’t
seem like much of a life after removing his stomach. Now I know
that’s not true.”
Tsuruoka called friends in Japan and the U. S. for advice, and
one suggested that he seek a second opinion. Smith identified
Zev Wainberg, an oncologist at the University of California, Los
Angeles (UCLA), who was involved in gastrointestinal cancer
research and clinical trials.
Smith and Tsuruoka met with Wainberg in December 2013, and
he connected them with a UCLA gastric surgeon, Darryl Hiyama.
Since the two doctors were not members of the medical group
designated by Tsuruoka’s Medicare plan, Smith had to argue to get
approval for him to see them. “My wife assembled the dream team
to treat my father-in-law,” says Tom Smith, Aki’s husband.
Hiyama explained to Tsuruoka and Aki that the stomach
functions as a holding chamber and a space to mechanically
break down food and mix it with fluid. It is the small intestine
that largely absorbs nutrients. If he did a total gastrectomy,
removing Tsuruoka’s entire stomach, Hiyama said, he would
attach Tsuruoka’s esophagus to his intestinal tract. Tsuruoka
would need to eat smaller portions more often throughout the
day and chew his food well, but he would still be able to eat.
Tsuruoka felt more comfortable with his new doctors and opted
to move his care to UCLA. “We decided Dr. Hiyama was captain
of the boat,” Tsuruoka says.
Tsuruoka gave Hiyama permission to decide during surgery
how much of his stomach to remove based on the size and location of the tumor. On February 11, 2014, Hiyama performed a
total gastrectomy. Tsuruoka’s 7.5-centimeter tumor was located
in the bottom portion of his stomach and had grown through his
stomach wall. Three of his lymph nodes were positive for cancer.
His cancer was stage IIIB.
Finding a Target
An estimated 26,240 people will be diagnosed with stomach
cancer in the U.S. in 2018, according to the American Cancer
Society, and an estimated 10,800 people will die of the disease.
While stomach cancer is not even among the top 10 leading
causes of death from cancer in the U.S. today, it was the most
common cause of cancer death in the U.S. until the late 1930s
and remains the third leading cause of cancer death worldwide.
In Japan, gastric cancer rates are more than seven times higher
than in the U.S. People who come to the U.S. after growing up
in a higher-incidence country like Japan are at increased risk
of stomach cancer. But second-generation Japanese-Americans
appear to be at lower risk than their parents, indicating that
environmental factors, like harboring the bacterium Helicobacter
pylori—which Tsuruoka was positive for—and the amount of
salty, preserved foods in one’s diet play a role in risk.
As an immigrant from Japan, Tsuruoka is in the higher-risk
group, but he is also typical of a U.S. patient because he was
diagnosed with stomach cancer that was no longer early-stage. Between 2007 and 2013, 27 percent of stomach cancers
in the U. S. were localized at diagnosis, while 28 percent, as
in Tsuruoka’s case, had spread to regional lymph nodes, and
35 percent had metastasized to distant sites. In Japan, where
there is a screening program for stomach cancer, almost half of
gastric cancers are diagnosed while they are still localized.
Outcomes for stomach cancer patients in Japan also tend to
be better than in the U.S. One reason may be that many patients
are diagnosed at an early stage. Hiyama says that Japanese
surgeons also tend to remove more lymph nodes during surgery,
with the theory that lymph nodes may harbor cancer cells
and contribute to the high rate of early recurrences in locally
advanced stomach cancers.
Shigeo Tsuruoka poses for a November 2017 family photo at a park
in Torrance, California. His daughter, Aki Smith, stands with her
husband, Tom Smith, who is holding their son, Kai Tomasz Smith.
Shigeo’s wife, Anna Tsuruoka, holds Jake, the Smith family's dog.