War and Peace in Cancer - The Words We Choose

What I sometimes witness is that this fighting language turns into something else when cancer progresses; people tell me they feel like they are losers in this war, and search for reasons why they did not win, often blaming themselves or some action they did or did not take at an earlier point.

The battle against cancer rages on- violence metaphors abound, making it harder to make peace. Can this be changed?

"I am certain I didn't fight hard enough. Maybe that break during chemotherapy was when I lost this one."

I heard these words a few months ago. The man who spoke them was lying on an examination bench opposite me in a hospital outpatient room. His oncologist had told him earlier that the cancer had spread, despite major surgery, chemotherapy, radiotherapy and even a newish drug that had shown some promise in trials. I was asked to give an urgent palliative care opinion, but really this was predominantly about helping someone who was frightened and felt guilt and remorse about his past actions and perceived inactions.

"I shouldn't have been such a wimp, shouldn't have capitulated. If only I had battled on through the nausea, the pain, the infection."

His anguish was expressed in his words, which were full of battle and fighting terminology throughout his illness- and now he felt utterly lost.

Human beings - we don't just 'have' cancer, we stand up to it, battle it, often we blast this wicked foe with an arsenal of systemic anticancer treatments. Militaristic turns of phrases abound, a patois to offer anyone affected by cancer the means to express their rage verbally. If you beat it, you are a survivor, if you don't beat it, you are portrayed as being on a journey that involves a long and brave struggle, during which victims soldier on, fight valiantly and ultimately, inexplicably fall. Heroically. This Sun newspaper article "Dear Cancer- fans share defiant one finger gestures", is one of many strewn with such language. Referring to the deaths of Alan Rickman, David Bowie and Lemmy, the journalist writes: "Devastatingly, the three national treasures all lost their battles with cancer in the last month. [...] At any given time, around 2.5 Brits [sic] are battling the deadly illness, according to MacMillian [sic]". The article describes fans' reactions, sharing images of one-finger gestures on social media in defiance of the enemy cancer.

Battle and violence metaphors are prevalent in cancer jargon, but less prevalent in other areas of healthcare, such as congestive cardiac failure or progressive kidney disease. "She bravely battled through schizophrenia," is not something that we hear often. As a cliché it is appealing and charities, healthcare workers, policy makers and the press often join in the use of violence idioms in their campaign adverts, posters, articles and reports.

I suspect that many people find battle and violence metaphors motivational in this context, perhaps most so when they are at the beginning of a diagnosis, and perhaps it is a way to cope with the impact of what they have just been told. When I see patients and their family members in the outpatient department or on the wards of our cancer hospital, the use of this kind of language is frequent, and I admit that I sometimes fall into its allures myself. My work is in palliative care, a specialty that deals with people who have terminal, incurable illnesses. I never discourage use of such metaphors, as that is not my role, but I do wonder when it started becoming so prevalent, with some patients seemingly feeling duty bound to express their war plan or battle strategy, perhaps as evidence to their friends and family that they aren't going to sit back and take this on the chin. I think it is likely I'd do the same, though, were I in a similar position. But I also think it reduces the likelihood of discussions around what someone would want at the time when the drugs just don't work (or make things worse) and when the end of life draws closer.

What I sometimes witness is that this fighting language turns into something else when cancer progresses; people tell me they feel like they are losers in this war, and search for reasons why they did not win, often blaming themselves or some action they did or did not take at an earlier point. Optimism is then largely replaced by fear of the unknown, the 'fighting talk carpet' has been firmly pulled from under their feet. Is it likely that the disappointment is now more profound, that the hard vernacular of battle did not allow for feelings of doubt, which are natural to the human condition. But where there is doubt, there are questions, so stifling one can lead to less of the other. Equally, there are those who do not wish to fight, but feel drawn into this battle by the prevailing Zeitgeist and through what they hear others say. 'I better put up a good fight for my family'.

It is clear that such language serves a purpose as well. Violence metaphors, when analyzed online by a group of researchers led by Elena Semino, were in fact found in some instances to be empowering.

But negative consequences from such language should not be underestimated, especially when diseases progress despite treatment. Explaining that she would curse anyone who ever uttered the words "She lost her brave fight," Dr Kate Granger, a terminally ill doctor in the UK, explained that she would not want to be remembered as a loser, refusing to believe her death will occur because she did not battle hard enough.

I have called this article War and Peace, but I have said very little about the latter. (It's just easier to write about war and violence, I suppose.) But peace metaphors do come into conversations I have with many patients and families, sometimes even early on into a palliative diagnosis. Here are some examples:

'I hope I'm restful and calm when I get more unwell.'

'I'd like to have my family around me, doting on me, making hot chocolate and listening to all our favourite songs.'

'I want to write some letters and be kind to a few people, a bit of reconciliation perhaps, before I get too unwell.'

'I'd rather go for a conservative approach in my treatments, something more moderate, less invasive and painful.'

'I don't really want a great deal of fuss, I just hope for a restful, smooth few years and to then bow out with some grace and serenity.'

'I want to be able to do some of the things I love, like the Saturday crossword'.

For the word 'love' or 'doting' to appear in a conversation with a medical professional is less common than the more typical fighting terminology I have described above. Equally, it is less common for a doctor to offer 'gentle' care or 'comfort' as a priority, except perhaps in those professions that prioritize this. For many the word 'Carboplatin' may have more appeal in someone needing end-stage cancer treatment, than 'Palliation', perhaps because a drug is that much more tangible, more immediate and implies that something is still being done. It palliates our helplessness, but not our illness.

Not that there is a lack of vocabulary available to us. The English language does not want for words that describe a quieter approach; the word 'tranquil' has at least 50 synonyms. I have found that the content of the sentences around 'peaceful' words is often far more focused on the outcome, rather than the journey or the treatment course.

When this rhetorical weaponry is laid down and we allow more harmonious, easeful language to describe aspects of our illness and the way we approach it, we may help remove some of the assumed heavy duties and burdens, too. Patients, families, friends and healthcare workers, when opting for more conservative, less aggressive approaches in language and the real life choices they make, may then stop wrongly fearing that they are choosing second best.

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