War Is the Wrong Metaphor for Cancer Care

Oncology Fellows, Vol. 14/No. 1, Volume 14, Issue 1
Pages: 14

The National Cancer Act of 1971 introduced the concept of a “war on cancer” and forever changed the way we discuss the disease.

The National Cancer Act of 1971 introduced the concept of a “war on cancer” and forever changed the way we discuss the disease. Cancer is the enemy. Patients are combatants. Physicians are strategists. And the weapons are surgery, radiation, and systemic thera-pies. There are victories and losses, comrades, allies, and—of course—survivors. But is this adversarial terminology helpful?

When I was a medical student, I met a man with colorectal cancer. We had enough discussions to decide that it was appropriate to proceed with his next cycle of chemotherapy, but I felt that he was holding some-thing back. After further exploration, I discovered that he was constipated and in pain. “I don’t mind the pain,” he said, “When I endure it, I feel like I am fi ghting my cancer."

As a resident, I met a woman with end-stage colorectal cancer. She had been so focused on fighting he cancer that she was not prepared to hear that there were no more therapies available. She had never considered any outcome but a cure and so had no idea how limited her time was. She told me that there was so much more she had wanted to do with her life.

We all have similar stories to tell. But these experiences made me reflect on what I could have done better, or differently, for those patients. I began to think about the language we use when talking with people who have cancer. Where does it come from? Which of our metaphors frame, for better or worse, the patient’s approach to the disease?

Metaphors are useful; they help patients and their loved ones understand complex biological processes and treatment approaches.1,2 But a war on cancer suggests that cancer is one disease with a single cause, approach, or cure, and that makes it more diffi cult for patients and their families to understand their options.3 I once saw a patient who received a strong recom-mendation to undergo adjuvant systemic therapy. Unfortunately, the patient sought advice from relatives with different types of cancer who had undergone only surgery or radiation. "Doing just fine now, Doc," he told me. "So, no thank you. I don’t want chemotherapy.”

The idea of fighting cancer creates a win-lose scenario that puts the onus for survival on the patient.4 Such language can cause those with a terminal diagnosis to think of themselves as 'losers ́ and to feel guilty or ashamed because they somehow 'didn’t fight hard enough. ́

The concept of war can maNe doctors focus on the biology of cancer to the exclusion of its social, psychological, and existential aspects and prevent us from exploring of the goals and values of our patients. Although medical treatment may keep patients alive, addressing their psychosocial/existential fears may enable them to truly live.

Within the military metaphor, declining treatment is equivalent to being cowardly or surrendering rather than being true to one’s values and ideals. Declining treatment can also cause strife between patients and those friends and relatives who don’t understand or agree with their choice, thus leaving patients without support systems.

When anticancer therapies are no longer effective, the metaphor can lead to the misconception that the oncology team has abandoned the patient and an inability to see the excellent palliative care these teams can and do provide.

Does the choice of words matter? Yes. In a survey of patients with breast cancer, most respondents preferred challenge to punishment or irreparable loss. Women who thought of their cancer in negative terms experienced signifi cantly higher levels of depression and anxiety, and had a poorer quality of life.5 In a study of men and women with dĭ erent types and stages of disease, those whose physicians spoNe only about fi ghting and having a positive attitude felt they needed to conceal their emotional distress.6

Physicians should put more thought into the words they use, without maNing assumptions about what will resonate with patients. We tend to employ adver-sarial terminology to encourage patients, but that can cause some to avoid talNing their illness experience. To many patients, such language gives no encouragement. Worse, it can lead to poorer quality of life, decreased overall survival, feelings of isolation, and the thought that they cannot choose palliative care.7-9

We need to explore our patients’ values and learn more about who they are as people, what their experiences have been, and what their priorities are for their journey through cancer. Then we might know what a win means to them.

Although metaphors, even the war metaphor, have value, it is our job as physicians to adopt the right one. If we allow patients to express their views on cancer, the metaphor that gives meaning to their experience will emerge, and we will be able to address their psychosocial as well as biological needs, identify patients who are struggling with their diagnosis, enrich the doctor-patient relationship, and perhaps even achieve better outcomes.

Adversarial terminology prevented one of the patients I met from seeNing treatment for constipation, impairing his Tuality of life. It robbed another of the time she would have had to pursue things that would have brought her joy. Their stories, and many others, have affected me as a physician and a person. They are a constant reminder of how much we can learn from patients. If we let them be active participants in their cancer journey, we can offer treatment that is in harmony with their goals and values—and produce better outcomes.

References

  1. Casarett D, Pickard A, Fishman JM, et al. Can metaphors and analogies improve communication with seriously ill patients? J Palliat Med. 2010;13(3):255-60. doi:10.1089/jpm.2009.0221
  2. Hansen PK. Illness and heroics: on counter-narrative and counter-metaphor in the discourse on cancer. Front Narrat Stud. 2018;4(S1):S213-28. doi:10.1515/fns-2018-0039
  3. Mukherjee S. The Emperor of All Maladies: A Biography of Cancer. Scribner; 2010.
  4. Sontag S. Illness as Metaphor. Farrar, Straus and Giroux; 1977.
  5. Degner LF, Hack T, O’Neil J, et al. A new approach to eliciting meaning in the context of breast cancer. Cancer Nurs. 2003;26(3):169-178. doi:10.1097.00002820-200306000-00001
  6. Byrne A, Ellershaw J, Holcombe C, et al. Patients’ experience of cancer: evidence of the role of “fighting” in collusive clinical communication. Patient Educ Couns. 2002;48(1):15-21. doi:10.1016/s0738-3991(02)00094-0
  7. Greer S, Morris T, Pettingale KW. Psychological response to breast cancer: effect on outcome. Lancet. 1979;2(8146):785-787. doi:10.1016/s0140-6736(79)92127-5
  8. Penson RT, Schapira L, Daniels KJ, et al. Cancer as metaphor. Oncologist. 2004;9(6):708-716. doi:10.1634/theoncologist.9-6-708
  9. Harrington KJ. The use of metaphor in the discourse about cancer: a review of the literature. Clin J Oncol Nurs. 2012;16(4):408-412. doi:10.1188/12.CJON.408-412