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Journal of Clinical Oncology, Vol 22, No 19 (October 1), 2004: pp. 4024-4027 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.03.136
Use of Metaphor in the Discourse on CancerFrom the Department of Community Health and Family Medicine, and Palliative Medicine Services, University of Florida Health Science Center—Jacksonville, Jacksonville, FL. Address reprint requests to Gary M. Reisfield, MD, Department of Community Health and Family Medicine, University of Florida Health Science Center—Jacksonville, 655 W Eighth St, Jacksonville, FL 32209; e-mail: gary.reisfield{at}jax.ufl.edu "I'm going to kill you. Every day, I'm going to kill you, and then I'm going to bring you back to life. We're going to hit you with chemo, and then hit you again, and hit you again. You're not going to be able to walk. We're practically going to have to teach you to walk again after we're done." Anonymous Oncologist1 INTRODUCTION With this metaphoric deluge, the oncologist lost a prospective new patient. A few hours later, Lance Armstrong was on a plane to Indianapolis, where he would establish a successful therapeutic relationship with the oncology team from Indiana University. Armstrong would, of course, survive widely metastatic testicular cancer and go on to win six Tours de France. While this epigraph may represent a well-intentioned effort by an oncologist to prepare a young man with an advanced, life-threatening malignancy for a long and immensely difficult course of treatment, the image of violence had a devastating and unintended effect. Armstrong himself, probably unconsciously mirroring the oncologist's martial metaphor, described the reaction in the consultation room as "shell shock." The comments of both the physician and the patient are emblematic of the fact that metaphors—and especially martial metaphors—play a ubiquitous, but largely unrecognized role in medical and lay discourse.2,3 Indeed, as a reader of the Journal of Clinical Oncology recently noted, the "target" in the title of this section of the Journal is itself a military metaphor.4 And as the above comments suggest, metaphors can be more than mere rhetorical flourishes; they can have a powerful influence on the practice of medicine and the experience of illness.2,5 "The essence of metaphor is understanding and experiencing one kind of thing in terms of another."6 Lakoff and Johnson have demonstrated that our conceptual systems are wired to operate metaphorically; that is, most concepts, particularly those that are abstract or complex, are at least partially understood in terms of other, more familiar concepts.6 Metaphors, then, are vehicles for understanding, mediating what is known and what is unknown.7 Mabeck and Oleson go further, arguing that metaphors don't merely describe similarities; they create them.8 When metaphors enter our conceptual system, they alter that system and the knowledge, attitudes, and behaviors to which the system gives rise.9,10 For the physician, metaphors can be time-efficient tools for helping patients understand complex biologic processes.10,11 For patients, metaphors can impose order on a suddenly disordered world, helping them to understand, communicate, and thus symbolically control their illness. And for the therapeutic relationship, the language of metaphor can serve as the basis for the shared understanding of clinical reality. We will examine the use of metaphor in oncology. We will focus on the predominant metaphor, that of war, in terms of its strengths and limitations, in the contexts of the patient-physician relationship and the patient's illness experience. Finally, we will briefly survey alternate metaphoric concepts. THE MARTIAL METAPHOR For physicians and patients alike, war is a dominant metaphor. There are several reasons for this: (1) This metaphor is ubiquitous in our society (witness, for example, the "wars" on drugs, poverty, illiteracy, and teen pregnancy). (2) It is easily adaptable to cancer, wherein there exists a seemingly perfect metaphoric correspondence: there is an enemy (the cancer), a commander (the physician), a combatant (the patient), allies (the healthcare team), and formidable weaponry (including chemical, biological, and nuclear weapons). (3) It connotes an unmistakable seriousness of purpose. (4) War has an exceptionally strong focusing quality, and its images of power and aggression serve as strong counterpoints to the powerlessness and passivity often associated with serious illness.12 The medical use of martial metaphors is not limited to physicians and patients. Pharmaceutical companies commonly use them in marketing their chemotherapeutic agents. One manufacturer of an aromatase inhibitor has designed a patient information Web site to help women "FIGHT HARD and FIGHT BACK in your battle against advanced breast cancer."13 An advertisement for another aromatase inhibitor—this one, "early breast cancer's daily opponent"—features a breast cancer patient donning hot pink boxing gloves emblazoned with the trade name of the drug. Another features a woman wielding a sword, in this case a visual metaphor for liposomal doxorubicin, and proclaims that it "fights as hard as she does." A patient support Web site announces that, "Jack is here today because he fought," and admonishes the reader, "You must fight, too,"14 and so on. For Cornelius Ryan, World War II historian and author, war was an enabling metaphor. Diagnosed with metastatic prostate cancer, Ryan was struggling to finish his historical novel, A Bridge Too Far, while undergoing aggressive antineoplastic therapy. He would detail his illness experience in A Private Battle. In it, he includes a letter to a friend, which he wrote while recovering from surgery: "About the best I can say to you is that I feel as though a half-track has rolled back and forth across my stomach nonstop for several days. I have a neat tattoo of the entire beachhead right across my abdomen... The attack was successful, although I am expecting a counterattack any moment from all sides, if any more of those nodes are malignant. Notwithstanding, I have surrounded myself by barbed wire, land mines, and several squads of infantry, and we are ready to take on all comers."15 Even when Ryan was dying, it was enabling for him to view his struggle through the lens of war. He strived to comport himself with the courage, grace, and dignity worthy of the sufferings endured by the soldiers about whom he wrote.15 Another patient, in the aftermath of the 9/11 terrorist attacks, came to think of his cancer as a terrorist group. He created several unique metaphoric correspondences: both events were internal threats; both were silent and hidden; both killed randomly; he feared and worried about what he used to ignore; removing one threat was no guarantee that others wouldn't be found; and, for both (in his case), there was no cure or viable method of prevention.16 Clearly, the martial metaphor resonates with many patients and physicians. Yet, like all metaphors, it has important limitations. The attributes that allow patients to comprehend certain aspects of the cancer experience in terms of war necessarily minimize or conceal other aspects. In addition, (1) it is inherently masculine, power-based, paternalistic, and violent.17 For some patients conflict, fighting, and war are not the preferred ways of coping with illness.12,18 As a patient with colon cancer noted, "The standard comparison of cancer as a war to be fought—a ‘battle with cancer’—was less than palatable. I had already experienced real war in Vietnam and was not anxious to repeat anything closely resembling that."19 (2) It suggests that winning the war (defeating the cancer) is only a matter of fighting hard enough.12 But for the vast majority of malignancies this is a serious misapprehension. Limitations in our weaponry and in our understanding of the enemy thus create inevitable (treatment) failures and losers. Thus, within the context of the martial metaphor, patients fail treatment instead of treatment failing patients, and the transition to a strictly palliative or hospice model implicitly represents failure. The desire to keep fighting, not to lose, to be courageous, may encourage physicians and patients to embark on additional, burdensome salvage therapies with little or no expected medical benefit. And in this culture in which quitting and losing are not acceptable, opting out of therapy can leave patients wracked with feelings of guilt and inadequacy. (3) There are conceptual weaknesses in the metaphor. There are no actual enemy invaders; the enemy is self. In this ultimate war of attrition, the weapons indiscriminately destroy the enemy (cancer cells) and the defenders (the immune system). And the battlefield is the patient's very body. Creaturo described the paradox thus: "The weapons being brought to bear are real and powerful, and they can turn quite treacherously against the very individual they're intended to protect."20 (4) It creates a focus on the biomedical parameters of the disease (eg, the scans, the counts) to the exclusion of the other aspects—social, psychological, and existential—of the illness experience. The rest of a patient's life is often disregarded or put on hold because all resources must be marshaled for the war effort. This intense focus may serve as a barrier to alternate understandings of one's life in the context of profound illness. Some of these limitations, as well as feelings of abandonment, are illustrated by the comments of Ric Blake, a patient with metastatic thyroid cancer: "Doctors, I think, don't get the nuts and the bolts. I have to look at my whole life, not just the disease, but my family, my job, my finances, my psyche. What concerns me then when the patient loses the battle, then they (the physicians) withdraw, they turn it over to someone else, and the patient's left fighting the rest of the war by themselves... I want them to stick there, all the way to the end. Just "cause we're gong to lose the war, doesn't mean that everybody has to leave the field."21 THE JOURNEY METAPHOR Life is a journey. This metaphor is so universal, and its referents so engrained in most cognitive lexicons, that it can be readily overlaid on lives that have been radically altered by cancer. And it may be particularly applicable to cancer in the 21st century, where the disease has largely been transformed from an acute event to a chronic illness, enmeshed in life narratives that may span years or even decades. Like the martial metaphor, the journey metaphor offers excellent cross-domain mapping. It allows for discussions of goals, direction, and progress. Quieter than the military metaphor, it still has the depth, richness, and gravitas to be applicable to the cancer experience. The cataclysm of a cancer diagnosis can compel patients to examine the authenticity of their journeys. The exigencies of serious illness can force them to exit the freeway of life on which they had been traveling, often on "cruise control," often at high speed, often with little thought of anything but arriving at the next destination. The freeway image is typically one of getting to some future state rather than living in the present. The alternate byways imposed by serious illness may involve suffering and uncertainty, but these may be tempered by the discovery of new sources of meaning; wells of courage, strength, and determination; and opportunities for personal growth. The metaphor encompasses possibility: for exploration, struggle, hope, discovery, and change. Importantly, the journey continues throughout cancer treatment and beyond. The roads may be bumpy and poorly illuminated at times, and one may encounter forks, crossroads, roadblocks, U-turns, and detours. The pace, route and destinations of the journey may change, sometimes repeatedly. The road may not be as long as one had hoped, and important destinations may be bypassed. But the journey metaphor does not countenance such concepts as winning, losing, and failing. Rather, there are only different roads to travel, various avenues to be explored, and, always, there are exits. Physicians may be trusted and knowledgeable guides, accompanying the patient throughout the journey, one that may ultimately imbue them both with a vision of a deeper meaning in life.22 OTHER METAPHORS Patients devise their own metaphors based on things they know and value, and are thus able to arrange their experiences in personally meaningful ways. Thus we see a plethora of creative metaphoric constructs for cancer, or specific aspects of the cancer experience, in the lay literature. Jack Martin, Vice President for Business at Northeastern University, adopted a building project as a metaphor for his cancer treatment. He developed a set of metaphoric correspondences (eg, setbacks such as radiation burns or neutropenia were "change orders" or "delays in the project") that helped him organize and communicate his cancer experience.18 R.V. Young, suffering from metastatic prostate cancer found resonance with the metaphor of scaling Mount Everest. Both experiences involved physical and technological challenges. Treatment became a dangerous uphill slog. His need for oxygen and a cane (his metaphoric "ice axe") were transformed from symbols of disability to necessary tools for traversing the steep slope.23 Other metaphors have included cancer as a chess match19,24; a marathon25; a drama26; a dance27; and a "collaborative exploration." 2 Lance Armstrong, not surprisingly, adopted the metaphor of the most important bicycle race in the world. When he began to show a response to chemotherapy he wrote: "I had opened up a gap on the field. I knew that if I was going to be cured, that was the way it would go, with a big surging attack, just like in a race... [the tumor markers HCG and AFP]... were my motivator, my yellow jersey... I began to think of my recovery like a time trial in the Tour (de France). ...I wanted to tear the legs off cancer, the way I tore the legs off other riders on a hill."1 CONCLUSION Metaphors are pervasive in the thought and speech of patients and physicians, and can have a profound effect on the cancer experience. They facilitate communication. They give coherence to the distinctive events of illness. And they can serve as powerful tools for establishing a consensual understanding in the therapeutic relationship, and influencing patient experience in ways that promote adaptation and positive self-regard.28 However, metaphors also involve a potential trade-off between the creation of greater understanding and the risk of dangerous misappropriation. Most physicians are only vaguely aware of the use of metaphor in clinical discourse.28 Simply by being mindful, physicians can develop an awareness of metaphorical language. Being conscious of their own use of metaphors, physicians can tailor their use to individual patients based on a multiplicity of unique patient characteristics such as personal and cultural values, specific aspects of disease, stage of illness, and prognosis. Ask patients if your proposed metaphors are appropriate. Be cognizant of the fact that some patients may find the use of certain metaphors inappropriate (eg, war) or dehumanizing (eg, the body as a broken machine). Listen for patients' metaphoric expressions. Elicit them if necessary. By paying attention to patients' metaphoric speech, physicians may gain some insight into the cognitive and affective underpinnings of their illness experience, and this may help make sense of their questions, their demands, their emotional responses, and their treatment decisions. No metaphoric concept is inherently good or bad. Each is contextual. Each has its strengths and weaknesses. Metaphors that are enabling for one patient can complicate the illness experience for another. Respect patients' metaphors but, if appropriate, try introducing alternate or parallel metaphoric concepts that may be more enabling. Metaphorical skill, imagination, and sensitivity are important in creating rapport and in communicating the nature of unshared experience.6 Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. NOTES Authors' disclosures of potential conflicts of interest are found at the end of this article. REFERENCES 1. Armstrong L: It's Not About the Bike: My Journey Back to Life. New York, NY, G.P. Putnam's Sons, 2000 2. Hodgkin P: Medicine is war: And other medical metaphors. BMJ 291:1820-1821, 1985
3. Mabeck CE, Olesen F: Metaphorically transmitted diseases: How do patients embody medical explanations? Fam Pract 14:271-278, 1997
4. Abratt RP: When the tumor is not the target: A title whose time is up? J Clin Oncol 21:4463-4468, 2003 5. Annas GJ: Reframing the debate on health care reform by replacing our metaphors. N Engl J Med 332:744-747, 1995 6. Lakoff G, Johnson M: Metaphors we live by. Chicago, IL, University of Chicago Press, 1980 7. Teucher U: Metaphor in crisis: The language of suffering. http://www.english.ubc.ca/projects/pain/dteuch/htm 8. Mabeck CE, Olesen F: Metaphors and understanding of disease. Ugeskr Laeger 158:7384-7387, 1996[Medline] 9. Skott C: Expressive metaphors in cancer narratives. Cancer Nurs 25:230-235, 2002[CrossRef][Medline] 10. Carter AH: Metaphors in the physician-patient relationship. Soundings 72:153-164, 1989[Medline]
11. Arroliga AC, Newman S, Longworth DL, et al: Metaphorical medicine: Using metaphors to enhance communication with patients who have pulmonary disease. Ann Intern Med 137:376-379, 2002 (part 1) 12. Hawkins AH: Reconstructing illness: Studies in pathography. West Lafayette, IN, Perdue University Press, 1999, pp 61-90 13. Femara Web site. http://www.us.femara.com 14. Cancer Battle Plan Web site. http://www.cancerbattleplan.com 15. Ryan C, Ryan KM: A Private Battle. London, United Kingdom, New English Library, 1981 16. Young RV: Cancer is not a cancer: My cancer journal. Year #3 2001. http://www.phoenix5.org/essaysry/rvycj1204NotCancer.html?FACTNet 17. Mitchell G, Ferguson-Pare M, Richards J: Exploring an alternative metaphor for nursing: Relinquishing military images and language. Can J Nurs Leadersh 16:48-58, 2003 18. Bowker J: Cancer, individual process, and control: A case study in metaphor analysis. Health Commun 8:91-104, 1996 19. Martin J: A monumental victory: Talk of the gown. Northeastern University Online Magazine. http://www.numag.neu.edu/9911/tog.html 20. Creaturo B: Courage: The Testimony of a Cancer Patient. New York, NY, Pantheon Books, 1991 21. Sherman M: One man's battle with terminal illness. Eagle-Tribune, Lawrence, MA, January 28, 2001 22. Olweny CL: Effective communication with cancer patients: Use of analogies—A suggested approach. Ann N Y Acad Sci 809:179-187, 1997[CrossRef][Medline] 23. Young RV: Climbing Everest: My cancer journal. Year #3, 2003. http://www.phoenix5.org/essaysry/rvycj110702everest.html 24. Drug information Web site. http://www.taxotere.com 25. Frank A: At the Will of the Body: Reflections on Illness. New York, NY, Houghton Mifflin Co, 1991, p 85 26. Noll P: In the Face of Death. New York, NY, Viking Penguin, 1990, p 174 27. Gibbs RW, Franks H: Embodied metaphor in women's narratives about their experiences with cancer. Health Commun 14:139-165, 2002[CrossRef][Medline] 28. Sims PA: Working with metaphor. Am J Psychother 57:528-536, 2003[Medline] Submitted March 22, 2004; accepted May 7, 2004.
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Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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