Characterizing cancer as a 'war' assumes it can be won. Is that too simple?

Try talking about cancer without using a war metaphor. It's likely you'll stumble.

We rarely say someone is living with cancer. People "fight" cancer or "battle" it. They demonstrate they are "warriors" and hopefully one day "survivors." Chemotherapy is a "weapon." The goal is to win "the war."

Patients, practitioners and loved ones frequently use fighting metaphors to characterize cancer. The competing metaphor, much less commonly used, describes cancer as a "journey." Many people living with cancer find fighting metaphors empowering, and they can be useful for loved ones trying to make sense of the abstractions of living with such an illness, who grasp for simple ways to talk about complex experiences.

But other cancer patients say fighting rhetoric doesn't resonate with them and can actually contribute to feelings of stress and inadequacy as they navigate fear, fatigue and the frustrating ambiguity that typifies so many of their diagnoses.

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Experts who study metaphors in health say there ought to be greater awareness of how language contributes to people's understanding of disease and especially how they fuel misconceptions about them.

"We've been using this language for so long, it's so conventional that we're just beginning to uncover what it's exposing about how we think about disease," said David Hauser, an assistant professor of social/personality psychology at Queen's University in Ontario whose research includes how metaphors guide understanding of disease. "A lot of cancer patients find this survivorship language to be an incredibly inept description of their experience."

How metaphors help people understand illness

Psychologists and linguists say metaphors, which allow us to think about one thing in terms of another, are useful for talking about concepts such as bodies and disease.

"Metaphors are deeply entrenched in our everyday language and in our everyday thought. And they give us a useful tool to think about new domains, challenging domains, to connect with other people," said Teenie Matlock, a professor at the University of California Merced who studies psycholinguistics and metaphor.

Hauser said "conceptual metaphor theory" suggests when humans try to understand abstract concepts – things that don't take a physical form, are complex, or that most people don't have experiences with – they are aided by metaphors.

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Time, for example, is an abstract concept, so people relate it to something more concrete. People think about time as if it's money – we spend time, we waste time, we exchange time. Disease is an abstract concept, so we relate it to war – the disease is the enemy, patients are warriors, therapies are our weapons.

President Richard Nixon signed the National Cancer Act of 1971, which the National Institutes of Health says, "represented the U.S. commitment to what President Nixon described as the 'war on cancer.'"

The rhetoric has persisted. During Breast Cancer Awareness Month in October 2008, former President Barack Obama released a statement that read, "Now is the time to commit ourselves to waging a war against cancer as aggressive as the war cancer wages against us."

For some cancer patients, fighting rhetoric can be empowering

A 2010 survey found oncologists used metaphors in two-thirds of their conversations with patients, and patients said physicians who used them were easier to understand.

Research shows many cancer patients find fighting metaphors empowering.

When a person is first diagnosed, Matlock said, it can be helpful to think about the team they're putting together to help them fight and the arsenal of tools available to help them overcome the obstacle. These metaphors can also be useful to patients who receive a grim prognosis.

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"If you're stage four and your outlook isn't very good, and you have doctors, nurses, friends, family, loved ones telling you, 'We're your soldiers. You be a warrior and we'll be here with you. We're all going to fight this battle,' that's empowering," she said.

A 2017 study on the use of violence and journey metaphors concluded: "some patients find meaning, purpose and a sense of pride and identity in approaching the illness experience as a fight."

In a 2018 paper Matlock co-authored, researchers argue war metaphors are omnipresent because they are effective, and "they reliably express an urgent, negatively valenced emotional tone that captures attention and motivates action." But they also cited research showing war metaphors can sometimes oversimplify issues and suggested they be used cautiously.

Other cancer patients say war metaphors cause stress

In a 2018 paper that looked at how metaphors help cancer patients cope, authors wrote that some patients, physicians, and researchers suggest "that a battle, inherently violent, masculine, and power-based, may not be a productive framing for cancer."

Framing cancer patients as warriors can leave some feeling guilty for not behaving in ways they believe an idealized "fighter" would. Cancer patients may be less apt to share how difficult things are, how fatigued they feel, for fear of not being seen as strong enough.

"Calling somebody a survivor or a fighter kind of conjures up this image of a superhero, someone who can shake off their hardship and live a normal life, and they're completely unaffected by their cancer experience," Hauser said. "A lot of patients just can't live up to that image because of the way that the disease works."

Perhaps most damaging, critics of war rhetoric say, is that the metaphor assumes if you fight hard enough, you can win, which distorts the realities of cancer. In one online forum, a cancer patient commented: “I feel such a failure that I’m not winning this battle."

"The war metaphor implies that patients have some degree of control over whether they beat cancer or not," Hauser said. "In many cases, that's not true at all."

Hauser said war metaphors can also have implications for public health.

"You can't really prevent something that has decided to attack you. Prevention is kind of a moot point at that juncture, but preventing cancer is important," he said.

Metaphors in cancer are helpful, but also limited

There is no one metaphor that can epitomize something as complex as cancer. Personal preferences and histories as well as the nature of each person's illness will determine what language best describes their experience.

Matlock and Hauser say it's important for people to observe and reflect on the language they use when speaking about cancer.

"Each person's experience is unique and metaphors help us make sense of the unknown, but they are limited in terms of how much explanation they can provide," Hauser said.

It's important to continually examine how language informs the way we think about some of the most difficult things we face.

"Talk to people with the disease. Listen to how they talk about it," Hauser said. "That's probably the only way to capture the complexity of their situation and to do it justice from a linguistic perspective."

This article originally appeared on USA TODAY: Breast Cancer Awareness Month: The power and limits of war metaphors