Does 'War on Cancer' Metaphor Cause Casualties?

Roxanne Nelson

January 06, 2015

Cancer is frequently referred to as a war zone, where patients engage in heroic battles against an insidious enemy. However, the popular war metaphor can have negative health implications, according to experts.

For example, the war metaphor is particularly ill-suited for prevention, according to the authors of a new study. And it can leave patients whose cancer progresses feeling defeated and depressed, says a clinician expert.

But although the war metaphor has great limitations, it should not be entirely disposed of because it does motivate some patients, according these sources.

Impairing Prevention Strategies

A report on the potential negative consequences of the metaphor was published in the January issue of Personality and Social Psychology Bulletin.

David Hauser, a doctoral student in psychology at the University of Michigan in Ann Arbor, and Norbert Schwarz, PhD, provost professor of psychology and marketing at the University of Southern California in Los Angeles, conducted three studies.

They found that, contrary to the prevailing wisdom that framing cancer as a feared enemy will motivate patients, enemy metaphors can have unintended adverse effects that can impair efficient prevention strategies.

Many of the behaviors that can reduce the risk for cancer, such as smoking cessation, limiting the intake of red meat and alcohol, and forgoing sunbathing, require a person to limit activities that they may find enjoyable. None of these fit well with a war metaphor, the authors note; limiting and constraining oneself is a concept that is not associated with battling an aggressive enemy.

"The metaphor alone does not make you do one thing or another by itself," Dr Schwarz noted. "It influences how plausible a recommendation seems and how intuitively appealing it is to follow through on," he told Medscape Medical News. "Recommendations that go with the dominant metaphor seem more natural and plausible than recommendations that go against the dominant metaphor."

However, he emphasized, the findings cannot judge the magnitude of impact. "Our data merely show that the metaphor influences perceptions of the recommendation and its effectiveness," Dr Schwarz said. "Future work has to look at the actual behavioral consequences. These studies are only a first step."

He pointed out that the studies did not involve actual cancer patients; members of the general public were recruited to fill out online questionnaires. So the data show that war metaphors do not increase motivation for active or more aggressive treatment in the population at large.

A Long History of Battle

Military metaphors for disease have been used for quite a while, although their popularity grew during the previous century. The first notable use of a military term to describe an illness is attributed to English poet and clergyman John Donne, who was stricken with a serious illness in the early 17th century and described it as a "cannon shot" and a "siege that blows up the heart."

In the mid-19th century, Louis Pasteur, one of the prominent scientists who developed the germ theory, began using military metaphors to depict microbes as invaders. In the early 20th century, there were "crusades" against diseases such as polio and tuberculosis, and scientists looked to find "magic bullets" and to develop more effective "weapons" to "fight" common ailments.

But cancer has been the most closely associated with the battlefield mentality. In 1946, Time Magazine published an article entitled Medicine: War on Cancer, which perhaps is not surprising, considering that World War II had just recently ended.

The metaphor really took off in 1971 when President Nixon publicly declared "war" on cancer, calling it a "relentless and insidious enemy." The authors note that this theme was popularized by "fear-appeal-based advertisement campaigns in the 1970s as a way to drum up funding for cancer research."

The Cold War was a real fear that gripped the public during this period, and advertisements for cancer research simply asked for governmental funding to deal with the cancer "threat," the authors note. Although times have changed, the portrayal of cancer as a perverse enemy has persisted.

"There seems to be agreement that the war on cancer was in line with the spirit of the time," explained Dr Schwarz. "It has pervaded public discourse to an enormous degree and there's probably no other illness with as many battles that patients win or lose. We don't talk about a patient's courageous battle with heart disease, for example."

Patient Backlash

Some patients have publicly expressed displeasure at seeing cancer portrayed as a battle to be fought. In a blog posted last year on Huntington Post, one young cancer patient wrote that even though her treatment has been successful thus far, she has "become entirely disillusioned with this idea that cancer is a race or battle to be won."

"I 'beat cancer,' but I don't feel like I won anything," she writes. "Others would say I've 'fought bravely,' but I know I'm not a hero. We use these imperfect metaphors to describe the indescribable experience of facing cancer, but I have to stop and wonder if these metaphors and clichés are doing more harm than good."

In a recent blog on McSweeney's, another cancer patient was more blunt. In an "open letter to people who use the battle metaphor for other people who have the distinct displeasure of cancer," she notes that "if I die of this relapsed, refractory acute myelogenous leukemia, and you describe me posthumously as having 'lost her battle with cancer,' I swear to God I will come back from wherever my soul may have been sent and haunt the living shit out of you for the rest of your days."

No Good or Bad Metaphors

However, war metaphors can also be helpful. Elena Semino, PhD, professor of linguistics and verbal art at Lancaster University in the United Kingdom, who has conducted extensive research on the use of metaphors related to cancer and end-of-life care, agrees that in many cases, these metaphors can have negative effects. "We have found that war metaphors can be detrimental for cancer patients, especially by creating feelings of guilt and failure when treatment does not work," she told Medscape Medical News.

"However, we have also found that these metaphors can be motivating for some patients," she explained. "While the battle metaphor is clearly unsuitable for many cancer patients, it seems to provide some with a sense of meaning, purpose, and positive self-identity."

Dr Semino and colleagues have found, in research not yet published, that no metaphor is always good or always bad, and that it really depends on the individual patient. What really matters is that no particular metaphor is censored or imposed on anyone; "rather, patients should be encouraged and enabled to use the metaphors that work best for them," she said.

Finding Consistent Across Studies

In their report, Hauser and Dr Schwarz describe the three studies they conducted to investigate whether framing cancer in terms of an enemy weakens a person's intention to engage in some of the more effective prevention behaviors currently available. None of the participants had had cancer.

Their first study involved 64 individuals who were asked about prevention behaviors after being randomly assigned to a group in which cancer was metaphorically framed as an enemy or to a group in which it was framed more neutrally. In the enemy-metaphor group, for example, participants were asked, "What things would you do to fight against developing cancer?" In the neutral group, they were asked, "What things would you do to reduce your risk of developing cancer?" Those in the enemy-metaphor group listed significantly fewer prevention behaviors, the researchers report.

In the second study, 313 individuals were randomly assigned to read one of three messages about colorectal cancer. The neutral message referred to a "growth of cancerous cells," for example, whereas the enemy-metaphor message referred to "a hostile growth of cancerous cells," and the imbalance message referred to "an unbalanced growth of cancerous cells."

Participants then rated the extent to which they intended to engage in various prevention, screening, and treatment behaviors. Those who read the enemy-metaphor message had less intention of engaging in prevention behaviors, such as limiting red meat intake or excessive alcohol consumption, than those who read the neutral or imbalance messages.

In answer to the question, "How much do you intend to engage in behaviors that are associated with a low risk of cancer?", participants who read the imbalance message intended to "self-bolster" more than both those who read the enemy-metaphor and neutral messages.

In the third study, as in the second, 162 individuals first read one of three messages about monitoring behaviors.

For example, the enemy-metaphor message noted that monitoring "detected colorectal cancer in its early stages when it is weak and easier for your body to fight." The imbalance message noted that monitoring "detected colorectal cancer in its early stages when it is smaller and easier for your body to restore balance."

In general, Hauser and Dr Schwarz report, the enemy metaphors in the second and third studies weakened intentions for self-limiting behaviors and were ineffective in altering intentions for self-bolstering prevention, monitoring, and treatment intentions.

"In contrast to the prevailing wisdom, enemy framing did not increase participants' intention to engage in effective monitoring procedures (studies 2 and 3), nor did it affect their preference for different treatment options," they conclude.

The studies received no outside funding. Mr Hauser and Dr Schwarz have disclosed no relevant financial relationships.

Pers Soc Psychol Bull. 2015;41:66-77. Abstract

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