Darrin Godin: Hello, and welcome to Talking Hope. I'm your host, Darrin Godin. Today I'm pleased to be in conversation with Dr. Yanghee Woo, a renowned surgeon, scientist, and global authority on stomach cancer, also known as gastric cancer. With her trifecta of clinical, research, and teaching experience, Dr. Woo leads leading edge programs in robotic cancer surgery and gastric cancer at City of Hope. She's also the director of the Gastroenterology Minimally Invasive Therapy Program at City of Hope, and she practices here at City of Hope, Orange County, Lennar Foundation Cancer Center, the most advanced comprehensive cancer center in Orange County. Welcome, Dr. Woo.
Dr. Yanghee Woo: Thank you, Darrin. Thanks for having me. It's a pleasure to be here today.
Darrin Godin: Well, let's jump right in. What do people need to know about gastric cancer?
Dr. Yanghee Woo: I think most important thing to know is that gastric cancer is curable, but unfortunately it's diagnosed in very advanced stages for most of our patients and then it remains very deadly to some of us ... some of our patients.
Darrin Godin: And why do you think that is? That it's curable but remains deadly?
Dr. Yanghee Woo: Gastric cancer is very difficult to diagnose. Most of the patients don't have any symptoms in its early development. And when the symptoms arise, they could be mistaken for some other diagnoses like reflux. And then by the time that the gastric cancer is actually detected, it can be in most of our patients in the United States, it's in advanced stages.
Darrin Godin: Is it a leading cause of cancer in the United States?
Dr. Yanghee Woo: No. Actually it's considered one of the rarer cancers in the US. However, gastric cancer affects more than one million persons worldwide. It is the fifth most common cancer after breast, lung, colorectal, prostate cancers. Gastric cancer happens to be very common in the world and amongst a specific sub ethnic populations, including Asians, Hispanic Latinos, and African-Americans. Gastric cancer also remains the fourth leading cause of cancer death where 75% of the patients who are diagnosed with stomach cancer in the world die from stomach cancer. So it's a very challenging cancer for us.
Darrin Godin: So it's very complex and challenging to diagnose, I hear you saying, and it affects certain populations more than others. You've mentioned some of the API community and communities of color. Do we know why that is or do you have an idea why that affects those populations differently?
Dr. Yanghee Woo: Sure. The ethnic heritage itself puts within a very heterogeneous population in the United States, identifies patients at risk. And so why is that? Well, there are certain risk factors perhaps that are more prevalent amongst our ethnic populations such as H. pylori, infection, family history, immigration from a high incidence country, and perhaps higher rates of smoking and drinking perhaps also exist in those populations as well. And so it's very multifactorial. And it's not just about ethnicity, but about socioeconomic status. One of the most alarming things about stomach cancer is that there is an increasing incidence of stomach cancer in the young population, especially amongst the young Hispanic men.
Darrin Godin: Wow. We continue to hear that message coming forth about the increased incidence of cancer, early onset cancer for younger folks. So even in gastric cancer, which is a more rare cancer, we're still seeing that as well. So interesting trends that are happening across the world and even here in
Orange County. Go ahead.
Dr. Yanghee Woo: Darrin, I want to correct myself in terms of how gastric cancer is rare. In the general US population, there are 27,000 patients diagnosed with gastric cancer each year. And the incidence rate because of the number of cases being low, is actually 6.9 out of 100,000 persons in the US population. And it ranks down in 15 after many different cancers. Unfortunately amongst Asian Americans and even subpopulation of Asian Americans like Koreans and Vietnamese and Hmong, the incidence rates can be 12 times higher, 10 to 12 times higher than in Asian-Americans, than the non-Hispanic White population and ranked amongst the top five cancers in this population. And also in the Hispanic and the African-American community, we see a higher of deaths due to gastric cancer when compared to non-Hispanic Whites. So these are some disparities that we face in stomach cancer. Because it's not one of the top cancers in the US, it's often ... not that much awareness exists about gastric cancer and what it's doing within our communities.
Darrin Godin: So clearly this impacts us here in Orange County, which is home to so many diverse communities. What are you seeing in regard to this in your clinic or in general? What are you seeing here locally?
Dr. Yanghee Woo: Yeah. So I love my patients. In the clinic, we see a lot of ... At City of Hope, we see a lot of very advanced patients, advanced stage gastric cancer. We also see a lot of patients that have had the long delays with months and months of upper GI, stomach related symptoms that have been misdiagnosed in some way, or even though they have stomach cancer diagnosis, they have found difficulty finding experts. So these are some alarming findings in our clinic. Obviously we're a tertiary cancer center and patients are coming to see us at City of Hope looking for experts in the field. There's not as many experts in gastric cancer as there are in colon cancer, for example, or breast cancer because just not as common as those. We also see young patients. I have unfortunately a large percentage of our patients that come to see us that are very young in their 20s, 30s, 40s with young children. They're supposed to be at the height of their lives, their careers, their family building and they get hit with stomach cancer.
Darrin Godin: Wow. That's an alarming thought. What do you think is the right step for patients then? If you're saying there are no screenings or the screenings are not available for that, it sounds to me like people often either miss symptoms or they don't even know they have this going on until it's advanced. So what is your recommendation for people in these communities who may be at a higher risk? What can we do for them, Dr. Woo?
Dr. Yanghee Woo: Sure. First, I think our health is our responsibility, our responsibility of our community, responsibility of the healthcare system, but also the responsibility of the individual. I think awareness about stomach cancer or gastric cancer is a must amongst the ethnic communities, especially in the Asian American, the Korean American, the Chinese American, the Vietnamese, as well as the different Latino American communities and the Black communities. Knowing that we are at a higher risk of developing gastric cancer will help us be more aware of our symptoms and that when symptoms come and go, it's very different from having symptoms that last a long time. Abdominal pain, nausea, inability to digest food, weight loss. We try so hard to lose weight. And when all of a sudden we lose weight without even wanting to do so, then that's kind of concerning. There's something wrong. Also, I think family members of elderly patients may need to be a little bit... Well, family members of elderly patients can also help in doing this.
I find that in different cultures, older patients want to hide or minimize symptoms. They have symptoms for a very long time. They select foods that may agree with them, even though they're not able to digest some things. They start to lose weight, but they don't tell their children because they don't want to burden them or they don't want to alarm them or worry them. So I think if we are observant of our family members, especially those who are elderly, about these symptoms, we may be able to identify symptoms that may be a cause of stomach cancer or other health problems.
So in clinic we see one-third of our patients are Hispanic, one-third of our patients a little bit more are Asian, and then the rest are non-Hispanic, Whites, Blacks and other. And some of them are mixed races. And all the cultures that they bring, the Armenian culture, the Persian culture, the Iranian culture, the Korean culture, the Vietnamese culture, they're very diverse in the way we deal with our cancers and the symptoms that they may have recognized but ignored for a while. So it's also our responsibility to seek help and know that there is help for stomach cancer patients and that we're here at City of Hope for patients that may need us for cancer care.
Darrin Godin: Well, you are both-
Dr. Yanghee Woo: And we speak many different languages. So we speak a lot of languages.
Darrin Godin: That's an exciting thing about City of Hope. I think it's one of the things that makes us stand out, makes us unique, and also demonstrates how much we care about our communities. That we are sensitive to those things that are culturally different for different groups of populations or different folks and we approach each person as an individual and we recognize that they're coming from different backgrounds. They may have different views or different concerns, and we address all of those in a culturally sensitive way and offer the cures that we can provide. I think that's a great thing about City of Hope that we don't toot our own horn about that enough.
Dr. Yanghee Woo: Yeah. So one thing I am very particular about in our clinics is our ability to provide in language care for cancer care. I think language is a ... Sorry. Language is very important and building bonds, and trust, and confidence. I wish I could speak all the languages of all my patients and I try to pick up a few words here and there. However, it could also become a very big barrier in the way we deliver cancer care to our patients and the ability to have someone translate their either in person or on a computer and express our assessments and plans. But mostly it's so that I can understand what the patients are going through.
I hear over and over again that patients are very happy when they're able to speak their language and they feel that we understand what they're saying because we have an interpreter or even sons and daughters who speak English for elderly patients. And I think this language is one of the most important things to break the language barrier. Well, first, because English is my second language and I used to have a New Jersey accent, which now disappeared. But it is something that is very important to me and my patients. So language also is part of a patient's culture. How they express themselves in our own language may not translate very well into English. So we want to be very sensitive to what the patients are saying when they're sharing information in a different language.
Darrin Godin: It's definitely part of who you are and it's a big part of being heard and seen for who you are. Dr. Woo, you are both a cancer surgeon and a cancer researcher. So I'd love for you to tell us what your current research focus is.
Dr. Yanghee Woo: Sure. Well, the research focus actually is dictated mostly by the most urgent need of our cancer patients. And I work very closely with gastric cancer patients and patient advocates to define what the most urgent needs are as well as seeing what is happening in our clinics, and in our country, and in the world in gastric cancer. So there's a lot of great progress going on. There are two areas that I think are the most important right now. One is in the care of patients with stage four gastric cancer who have their cancer spread to the peritoneum inside the abdomen. I think the patients who have gastric cancer with peritoneum metastases actually have the worst prognosis because we don't have directed therapy specifically for this patient population. It is the most common site of the metastasis from stomach cancer. When stomach cancer travels outside and it's not under control, it likes to go to the peritoneum.
Where is the peritoneum? Well, it's the inside lining of our abdomen. When you have the skin on the outside, well, inside, there's also a skin called the peritoneum. And for some reason, stomach cancer likes to go there. It's hard to find, hard to see in the beginning, extremely difficult to treat with the current therapies, the systemic treatment that we have that we get IV like chemotherapy and immunotherapy. And once they occur and they become treatment resistant, they cause a lot of problems like fluid in the abdomen, obstruction of our small bowel. They create masses that get in the way. Our patients can't eat, they lose weight and it impairs the quality of life and the treatments are still very lacking.
So the research that I'm doing is twofold. One is to understand the immune microenvironment that is existing in our peritoneum of gastric cancer patients to better characterize them and to identify targets for immunotherapy. One of the immunotherapies that we're investigating are oncolytic viruses, cancer killing viruses that attack cancer cells. And then the viruses can express certain genes and proteins that can be targeted. So there's some exciting developments there. And identification of new targets on those cancer cells that are in the peritoneum and immune cells that will help us attack the cancer cells, that's one. But while we're doing this urgent investigations in the lab that we hope to bring to human trial very soon, there is something that we need to do right now that will help us for all of our patients that do not have stomach cancer, but at high risk of developing stomach cancer or gastric cancer. And that is to develop a feasible and workable plan for early detection of stomach cancer so that we can catch stomach cancer very early and I can cure it. Surgeons can cure. And my colleagues, my gastroenterologist colleagues like Dr. James Lin and Greg Idos and Dr. Lance Uradomo, who is actually down at Orange County at Lennar. We are able to cure early gastric cancer. When gastric cancer has not penetrated through the walls or spread into the lymph nodes, gastroenterologists and surgeons can cure our patients.
However, because the symptoms do not exist for a while, we need to have a method of detecting cancer early. And in countries like Japan and Korea where incidents of stomach cancer is very high, there are screening programs for stomach cancer. In the US, we have screening programs for colon cancer, breast cancer, lung cancer, and prostate cancer and cervical cancer. These are cancers where we can identify persons at high risk, certain age, smokers, et cetera. In stomach cancer, we also can identify patients at risk or higher risk compared to the general population and where the incidents are high. So we have developed a study, a two tier assessment, two tier screening program where we want to identify persons at risk of developing stomach cancer. I call it two tier because the first tier is the risk assessment. Second tier is to offer the gold standard of stomach cancer diagnosis, which is upper endoscopy. The upper endoscopy is like a colonoscopy, but in the other direction, and it's performed by gastroenterologists. A simple method of looking down directly into our stomach and to also to biopsy the stomach wall to find any abnormal cells, whether they're pre-malignant or cancer.
So the first tier is to risk assess a population, meaning the risk factors such as what we had described previously. Family history of stomach cancer, age. So older you are, the more risk points you will get. Did you have H. pylori? We'll test everyone for H. pylori who joined the study. If you are positive for H. pylori infection, then you are at high risk of developing gastric cancer or higher risk. Did you immigrate from a different country? Do you previously have stomach polyps? There's many questions that we were going to ask to assess for risk. Are you Korean? If you're a Korean man, you get the highest number points because you're at the highest risk. If you are a Korean man smoker, then you even have a higher point deeming you at higher risk. And so all these points along with a visit to the hospital to speak with a doctor, actually speak with me and consult about the risk factors, the possible symptoms associated. And ultimately, if you meet those points deemed to be high risk, then you will be offered an upper endoscopy.
I expect that this study, it's not a big study, but it will help us understand the acceptance of such a program. A screening program is only successful if the community is willing to accept or the American public is able to accept and want to do the screening. The screening program is not going to be successful if no one wants to do the screening, right? That's how screening fails. But if the population is willing to accept it, and I believe our population would be, we're going to study this right down in Orange County, LA County. So right here in Southern California, we're going to be ... we have already launched and we have already enrolled three patients, which is super exciting.
Darrin Godin: It is.
Dr. Yanghee Woo: I expect that this study is going to finish and accrue very soon and give us information about out the communities, the persons who live in our community, the risk factors that exist there, our willingness to come and get a screening program and engage with healthcare professionals to get care for their stomach health. It's called our stomach health because it's not just about cancer, but being healthy in our lifestyle.
Darrin Godin: Well, you are a very busy person, obviously actively seeing patients, being a surgeon, you are doing research in the lab, you're doing research in communities. We want to help you get that word out. We will put the website in the show notes for our stomach cancer where other folks can get more information on that. And certainly we ask that folks to share that with their friends and their loved ones in these communities of concern. I want to move on because I know we're just about out of time and you've got to get back to patients. I found out something interesting about you. Your name, Yanghee, actually means something interesting as it relates to the work that you do here at City of Hope. So is it correct to say that Yang means bright and hee means hope? So your name is Bright Hope.
Dr. Yanghee Woo: Yes. It actually does. So the Chinese characters ... Although I'm Korean American, the name actually has Chinese characters behind them. And the Chinese character for Yang means bright for my Chinese character and hee means hope. And so it was given to me by my great-grandfather, and I'm grateful for it.
Darrin Godin: Very fortuitous for the work that you would end up doing in this research that you're doing. So let me ask you this question then, Bright Hope. What does the concept of hope mean to you specifically when it comes to caring for patients with cancer?
Dr. Yanghee Woo: It's going to make me cry. So sit back a little bit.
Darrin Godin: I'll be Barbara Walters. Let's cry, Dr. Woo.
Dr. Yanghee Woo: I learned that more important ... Oh, my gosh. I really am going to cry. But more important than what is expected of all of us as cancer surgeons, we are expected to have great knowledge and exceptional clinical acumen and be really good in the operating room where errors are not acceptable. But beyond that, to the patient that I have met in the last, I don't know, 20 years of training and being a surgeon responsible for my patients, they have taught me that hope is probably the most important aspect of cancer care that we could offer to our patients. And so it aligns with my name and I hope to live up to that. And it's a privilege to be able to be in a situation and where every day I can offer hope to my patients. I hope that it comes across like that, that every patient that walks into the clinics onto campus, whether it's at Lennar or at Duarte, at City of Hope, that we brightly shine hope as they enter.
So when I first came to interview at City of Hope nine and a half years ago, one of the things that warmed my heart, and I didn't realize it until afterwards, is that there's a fountain of hope that we drove up to. And it just provided me with a sense that if I want to work here, because when patients come here, I feel like they would feel like they were healing. And so cancer cures are not afforded to everybody at this moment, but cancer hope and healing can be offered to everybody, and that's what I feel like we are responsible to do. That's what I wake up every morning and hoping ... I drive to work and say, "Today, that's what we need to do." And that's why the research that we do is so important, that's why we have to work a little bit harder than everyone else. You sleep a little less. Surgeons don't sleep a lot, by the way. So we sleep a little less, we work a little bit harder.
So to give the gift of hope to our patients is our privilege. So hope is to know for all of those who are out there seeking treatments for cancer, that there are people working really hard to move the science forward to make sure that the cures are available soon. Somebody just taught me a word at a research conference. They said the word yet, and I'm going to use that word. Well, we don't have the cure yet, but we are going to have it soon. But in the meantime, we're going to do our best to treat and to offer hope and to heal the cancer that our patients have. Gastric cancer is really stubborn. It is like my biggest foe. It's really tough, but it's not going to beat us. One day we're going to find a cure. And the goal of our entire program, our gastric cancer program, is to eliminate deaths due to gastric cancer. It's going to happen hopefully in my lifetime, but if it's not, we'll get very close to it.
Darrin Godin: Well, here, cheers to that for sure. And so well said the way you described hope. And so thank you Dr. Yanghee, Bright Hope, Dr. Woo, for sharing that. And thank you for joining us on the podcast today. With gastric cancer or any cancer, you can't pick your battles, but you can choose your warriors. We have one of them with us today on the podcast. Cancer is never easy, but it starts with hope. First in research, first in treatment, first in survival. When it comes to cancer in Orange County, it's hope first. We invite you to visit cityofhope.org/oc to learn more. To make an appointment at any of City of Hope's Orange County locations, you can call us at 888 333-HOPE. That's 888-333-4673. I'm Darrin Godin. Thank you for joining us on Talking Hope, and we hope to see you next time.