More Than Conquerers
Communication within cancer care is saturated with metaphors.
During her two third-years — the research years from Fall 2020-Spring 2022 — Bodd led a small qualitative study aimed at understanding the function, frequency, and impact of metaphors, particularly the war metaphor, on the patient experience, from cancer diagnosis through treatment and survivorship. ("More than conquerors": a qualitative analysis of war metaphors for patients with cancer, Supportive Care in Cancer, Dec. 2022)
“There is plenty of literature about war metaphors like "fighting cancer" in oncology, but there has been no rigorous qualitative analysis,” Bodd explained.
Her study was a place to start. The research team — drawn from DCI, Dana-Farber Cancer Institute/Harvard Medical School, Brigham and Women's Hospital, and Oregon Health and Science University — interviewed 15 patients with breast, lung, or colorectal cancer, at various stages of progression, using an interview guide developed with input from social workers and DCI patient navigators.
The DCI-site research was conducted under the auspices of the Duke Cancer Patient Experience Research Program, which is led by Duke Cancer Institute Chief Patient Experience and Safety Officer Thomas LeBlanc, MD, MA, MHS, a hematologic oncologist and palliative care physician. LeBlanc was the senior author of the paper.
When patients who used the war metaphor were asked, ‘Where did you first hear this metaphor, or when did it start to gain significance for you?’ respondents said they found it in the community, on the signs entering a cancer hospital (not Duke), or in their support groups, explained Bodd, and they tended to use the war metaphor in conjunction with another metaphor.
"Most patients used metaphor themes of journey, nature, war, or mystery to describe their cancer as a way to make meaning out of their diagnosis, possibly as a coping strategy,” the investigators reported. “All patients with non-metastatic disease used war metaphors and described how these metaphors facilitated meaning-making by promoting positivity and situating cancer within a larger life story. The few patients who did not use war metaphors had metastatic disease, and they explained that war metaphors were unhelpful due to feeling a lack of control over their metastatic disease and outcomes.”
Noted Bodd, “One patient with metastatic disease said, ‘I feel like my body with cancer is a battlefield, and the oncologists are the fighters.’” Imagining that their body was “caught in the crossfire,” observed Bodd, speaks to how the war metaphor “isn’t quite as useful” as it “doesn’t give patients agency” over the outcome.
Some included God in the equation.
“For example," she said, "one patient endorsed that ‘God can fight cancer and has fought cancer. So, cancer isn’t bigger than the God that I know that I serve.'"
The investigators concluded, “The war metaphor should remain an integral part of cancer care. Disregarding war metaphors robs patients of an important framework for meaning-making, one that may promote strength, continuity, and resilience in navigating cancer.”
These findings got some attention in clinical circles.
“Anyone familiar with cancer will attest to the association of war and battle metaphors in survivorship,” began an article on ‘Cancer and War Imagery’ in Cancer Nursing Today. “Having to ‘battle’ cancer or even ‘the battlefield’ are common colloquialisms peppered into the everyday vernacular surrounding cancer. Despite the frequency of usage, it remains unclear whether this terminology is helpful or harmful to patients with cancer.”
The article went on to cite a 2019 piece in The Guardian newspaper suggesting that war idioms might increase fatalistic views of cancer, then presented, as a counterpoint, Bodd’s study conclusions that the usage of war metaphors “could be helpful for some patients.”
Joshua Briscoe, MD, a hospice and palliative care physician at the Durham VA Medical Center and assistant professor of Psychiatry and Behavioral Sciences at Duke, engaged Bodd over Twitter about the study findings.
“Of all the metaphors, the war metaphor is the most rigid. It doesn’t permit the possibility of other outcomes beyond winning/losing. It flattens the moral landscape of healthcare,” he wrote. “Nearly all the patients I see have a limited life expectancy, so the war metaphor carries too much win/loss. I might have a different view if I saw more patients who were being cured.” (Read Briscoe's commentary piece on faith, living, dying, and cancer in Mere Orthodoxy for more of his insights.)
Though the study team did not interview clinicians, Bodd agrees that a study about how clinicians engage or don’t engage with the “cancer battle” would be worthwhile.
“From anecdotal experiences in talking to physicians, whether medical or surgical oncologists, some of them say they don’t follow their (the patient’s) lead about the war metaphor; i.e. if the patient uses it, they still don’t use it. There are some who use it if the patient introduces the metaphor into this space. And some physicians do introduce the metaphor themselves,” she said, noting that only one study participant said their doctor introduced the war metaphor.
Noted Briscoe, “It would be helpful to know how metaphors influence clinicians’ own practice… whether they view themselves as fellow warriors, companions on a journey, coaches, or mere scientists… I appreciate the authors’ work here because clinicians do need to be more mindful of how metaphors and language in general operate in the clinical encounter… We (as clinicians) need to listen, so we can respond appropriately.”
