No More Magic Bullets
In the wake of the Sandy Hook massacre, it’s time for reflection on how to make 2013 a better year. In the house of oncology, we may want to stop using our words as weapons.
As doctors, we are responsible for not only understanding disease processes but explaining them to our patients. There was a time when cancer was scary enough conversation wasn’t possible. And when Nixon started the ‘war on cancer’ with passage of the National Cancer Act in 1971, it has the potential to empower us when before it was too frightening to even mention. We have made tremendous progress in understanding cancer at a molecular level. But the war metaphor may limit what progress we can make.
Disease as adversary
Cancer is a ‘killer’, invading the body and can be malignant. Rapidly growing tumors are ‘explosive’, slow growing ones may be ‘smoldering’ but just waiting to advance.
Patient as battleground
From the outset, patients are sent to war. Newly diagnosed patients are recruited into the militaristic model to fight. The alternative is to be loser in a metaphorical battle, or to be a victim if one choose not to fight.
Sacrifice is required in wartime. Patients are advised to accept surgery, chemotherapy and radiation therapy. times like this, it’s harder to ask questions without being seen in a negative light. Unfortunately, the rush to action sometimes means misunderstanding treatment options and poor informed decision-making. It can lead to decisional regret, emotional or physical health consequences.
It’s a win-lose proposition in war, but even the ‘winners’ often are left with ‘battle scars’ and emotional distress. We don’t use the word cure in oncology, which leaves the perpetual need for readiness and the need the return to the field of battle. When recurrences happen, often we discuss ‘salvage’ therapy. Who wants to be seen as a failure with maybe a second chance?
Clinician as aggressor
Usually it is doctors who formulate the ‘plan of attack’. Our decisions may be rational, but with the language we use sometime it seems more like we’re field generals rather than healers. Even with the successes of molecular medicine: “we are moving from the indiscriminate use of large-scale carpet-bombing to the pinpoint accuracy of guided missile attacks.” Whether those missiles are molecular ‘targeted’ pharmaceuticals or ionizing radiation, we are authorizing treatment which may have lasting collateral damage.
At any price?
The financial cost of cancer care continues to rise, and the war metaphor may make it more acceptable to pursue very expensive treatments with little proven benefit. This concern may apply to experimental testing, drugs, and proton therapy. Even after cure, patients may face indebtedness which hurts their quality of life and may compromise their families’ future well being.
A new narrative
We have made so much progress in understanding cancer as a wide constellation of proliferative diseases in the past 40 years. But I pledged to be a healer, not a fighter. It’s time to put our weapons down and find a new way to explain and treat cancer.
Don Dizon, The Language of Cancer, ASCO Post, 2012
Gilles Frydman, Terrorized by the ‘War On Cancer’, E-patients.net 2009
Mike Marqusee, I Don’t Need A War To Fight My Cancer, The Guardian, 2009
Ellen Ormond, Avoid The War Metaphor In Cancer Treatment, New York Times, 2009
Richard Penson et al., Cancer as Metaphor, The Oncologist, 2004
Susan Sontag, Illness as Metaphor, 1978
Melinda Wenner, The war against war metaphors, The Scientist, 2007
Editor’s Note: Matt Katz, MD is a member of the External Advisory Board for the Mayo Clinic Center for Social Media.