Is War a Good Metaphor for Cancer Care?

The National Cancer Act of 1971 introduced the concept of a “war on cancer,” which has since affected the language we use when discussing cancer. Cancer is the enemy. Patients are combatants. Physicians are strategists. Systemic therapies, radiation therapy, and surgery are the weapons. There are the wounded, comrades, allies, victories, losses, and of course, survivors. But does creating this adversarial relationship with a patient’s cancer really help?

As a medical student, I met a patient with colorectal cancer. During one visit we discussed proceeding with his next cycle of chemotherapy, but it felt as though he was holding something back. With further exploration, I found that he was constipated and in pain. “I don’t mind the pain,” he told me. “When I endure it, I feel like I am fighting my cancer.”

As a resident, I met another patient in the end stages of a hematologic malignancy. She had been so focused on “fighting” her cancer that she was unprepared to hear that no more systemic therapy options were available—she had never considered any outcome other than a cure. As a result, she had not understood that time was limited; she told me that there was so much more she would have wanted to do with her life.

We have all seen patients with similar stories. These experiences have made me reflect on what we could have done better, or differently for those patients. I started looking at the language we use when we engage our patients in a discussion about their cancer. Where does the language that we use come from? What metaphors might we be using that for better or worse may frame a patient’s approach to their disease?

Metaphors can be useful tools to help patients and their families understand complex biological processes and approaches to treatment.^1,2 However, not all metaphors resonate with all patients. The terminology of a single war on all cancer suggests that cancer is just one disease with one cause that has one approach or cure, making it more difficult for patients and their families to understand their options and recommendations.³ For example, I saw a patient for whom adjuvant systemic therapy was strongly recommended. The patient sought advice from relatives with cancer types different than theirs, and who only received either surgery or radiation, and I was told, “My family members are doing just fine now, so no thank you. I’ve already had surgery; I don’t want chemotherapy.”

The concept of “fighting” cancer creates a win-lose scenario and puts the responsibility for both getting cancer and surviving it on the patient.⁴ Such language can cause patients with a terminal diagnosis to think of themselves as the “loser,” and feel guilt or shame because somehow, they did not fight hard enough.

The concept of war can create a focus on only the biological aspect of cancer, excluding considerations for the social, psychological, or existential aspects of the illness experience and preventing an exploration of the patient’s goals and values. Although treating the biological aspect with medical therapies may keep a patient alive, addressing psychosocial/existential factors may enable someone to truly live.

The idea of declining treatment within this metaphor is depicted as cowardly or giving up, as opposed to an appropriate choice for a patient who is being true to their own values and ideals. This can create strife between patients with cancer and their family and friends who may not understand or agree with such a choice, thereby isolating patients from their support systems. It can also lead to the misperception that the oncology team has “abandoned” a patient once anticancer therapies are no longer viable, ignoring the excellent palliative care that oncology teams can, and do, provide.

Does our choice of words matter? In a study of patients with breast cancer, most respondents preferred words like “challenge” or “value” to derive meaning from their cancer, rather than terms like “enemy” or “irreparable loss.” Women who described their cancer negatively with words like “enemy,” ”loss,” or “punishment” had significantly higher levels of depression and anxiety, and a poorer quality of life (QOL).⁵ In another study that included patients with a variety of disease sites, those whose physicians exclusively promoted the idea of “fighting cancer” and a “positive attitude” felt the need to conceal emotional distress and to protect their family members from their distress.⁶

Physicians can be more thoughtful about the language they use without making assumptions about the language and motivations that will resonate with their patients. We tend to use adversarial terminology to discuss cancer and to encourage patients, but this does not engage all patients in a discussion on their illness experience. Adversarial language may not provide encouragement for some and can, in fact, lead to a poorer QOL, decreased overall survival, isolation, and a perceived inability to choose a palliative approach to care.^7-9 Instead, we can explore a patient’s values and learn more about who they are as a person, what their experience has been so far, and what their priorities are for their cancer journey. This can help to redefine what a “win” means for that patient.

Metaphors, even the war metaphor, can have value. However, it is our job to find the right metaphor for individual patients. If you follow your patient’s lead, an appropriate metaphor can bring the patient’s subjective view of their cancer to the forefront and give meaning to their experience or serve to identify those who are struggling with their diagnosis and journey. In doing so, we can better address the psychosocial concerns of patients, in addition to purely biological ones. Being on the same page can also enrich the therapeutic relationship with a patient, and with better communication comes better outcomes.

In the cases I described above, an adversarial approach stopped the first patient from seeking treatment for his constipation and significantly impaired his QOL. I believe it also prevented the second patient from communicating her goals and values and kept her from pursuing those things in life that would have brought her meaning. These stories, among others, have been significantly impactful on me as a physician, and as a person. They are a constant reminder that we have so much to learn from our patients. When we allow patients to serve as guides and active participants in their cancer journey, we can provide treatment that is consistent with their individual goals and values, as well as 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):255-260. 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-S228. 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

This article was written by Courtney Coschi, MD, PhD, a medical oncology fellow at Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada.