This Is Us (2016) and Stage Four Stomach Cancer

This Is Us braids the Pearson family across decades. On his thirty-sixth birthday, Randall Pearson, adopted as a newborn, tracks down his biological father, William Hill. William is a Black poet and recovering addict living alone in Philadelphia. He has stage-four stomach cancer, he has stopped chemotherapy, and he knows it is terminal. Randall moves him into the family home.

Over the season William becomes part of the household. He reads with Randall's daughters. He disarms Randall's wife Beth. Randall discovers that his mother Rebecca knew where William was all along.

Off treatment, William has a spell of renewed energy. As his health slides, Randall drives him to Memphis, his home town. They visit his old house and his cousin's club, and the band lets him play once more. The next morning he is barely conscious. He dies in hospital with Randall beside him, leaving letters for the children and a postcard for Beth.

The ending is described here in full.

The most valuable thing this story does is start after the decision.

William arrives having already concluded that more chemotherapy is not worth what it costs him. Nobody in the family treats that as surrender. Nobody tries to talk him into one more line of treatment. For a mainstream drama, that is unusual and it is humane.

The short lift in energy and appetite that follows is something families describe too. When treatment stops, some of the exhaustion that was treatment rather than cancer lifts for a while.

What the show never says out loud is that stopping cancer treatment and stopping care are different decisions. One ends the drugs aimed at the tumour. The other would end the drugs aimed at pain, sickness and sleep, and nobody sensible ends those.

Going back to Memphis is a recognisable kind of plan. Return to a place. Settle an old quarrel. Be seen as the person you were before you were a patient.

Requests like this are common near the end of life, and they are not frivolous. They give a dying person something to organise and a role other than patient.

What the show removes is the logistics. A long car journey with advanced stomach cancer means planning medication, eating, pain control and what to do if things go wrong far from home. That planning is usually possible. It is just not free, and a team needs to be involved.

Randall's caregiving is drawn honestly: proud, private and quietly coming apart. He does not ask for help, and his family only sees it when he breaks.

That is what carer strain usually looks like from the outside, which is why it goes unnoticed for so long. The person doing the caring is competent right up until they are not.

The letters and the postcard William leaves are the other half of it. Legacy-making is real work, and doing it deliberately tends to help the people left behind.

William takes no visible medication. No palliative care nurse, hospice team or symptom-control plan ever appears on screen.

He also stays comfortable, articulate and mobile for a very long time. NCI's description of advanced stomach cancer is harsher: vomiting, stomach pain, trouble swallowing, weight loss with no known cause, blood in the stool, jaundice, and ascites, meaning fluid building up in the abdomen.

The final stretch, where he goes from a little weaker to unresponsive inside a day, does match how fast advanced cancer can turn. Almost everything before it is smoothed.

The diagnosis is delivered as backstory. There is no endoscopy, no biopsy, no staging scan. So the show never shows the part a viewer could actually use.

NCI is blunt about the problem. Early on, stomach cancer usually causes no symptoms, and symptoms typically begin after it has spread. When early symptoms do appear, they are:

• indigestion and stomach discomfort
• a bloated feeling after eating
• mild nausea
• loss of appetite
• heartburn

That is a list of reasons to buy antacids, not to see a doctor. Which is the point. Upper-abdominal symptoms that persist in an adult, or that are new and do not settle, deserve investigation rather than another month of self-treatment.

NCI states plainly that in the United States there are no standard or routine screening tests for stomach cancer in people at average risk, and that researchers are still working on them.

Some countries where the disease is far more common do screen with endoscopy. That does not transfer automatically. A test's value depends on how common the disease is in the population being tested, and stomach cancer is much rarer in the US.

Endoscopy is also not free of harm. NCI lists false negatives, false positives, and rare but serious complications including a perforation of the oesophagus or stomach, severe bleeding, and breathing or heart problems.

NCI names groups who may benefit from screening with upper endoscopy: older people with chronic gastric atrophy or pernicious anaemia, people who have had part of the stomach removed, people with a family history of stomach cancer, people with certain genetic syndromes, and people from countries where stomach cancer is more common.

Two things sit alongside that. Long-term Helicobacter pylori infection is a major risk factor, and NCI states that treating it reduces the risk of these stomach cancers. It can be tested for. Inherited conditions such as hereditary diffuse gastric cancer are managed by specialists, and preventive surgery is sometimes offered.

Risk is also not spread evenly. NCI reports that men are nearly twice as likely as women to be diagnosed with stomach cancer, and that Black men are nearly twice as likely as White men to die of it. William Hill sits in that statistic, and the show never mentions it.

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This Is Us is good on the family around a dying man and thin on the illness killing him. Watch it for Randall and William. Do not read it as a description of stage-four stomach cancer.

Two things are worth taking away. Indigestion that keeps going in an adult is worth investigating, not managing forever with antacids. And an H. pylori test is a cheap question to ask if you have a family history.

For more, see screening and possible warning signs.

• NCI — Stomach Cancer Symptoms
• NCI — Stomach Cancer Screening
• NCI — Stomach Cancer Causes and Risk Factors

This page discusses This Is Us for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email corrections@cancerexplained.org.