Can We Stop Calling Cancer the ‘Big C’?

Nick Mulcahy

April 08, 2016

An editorial published in the March issue of the influential Lancet Oncology has declared that cancer is "no longer the big 'C'," and now "must be appraised realistically."

The reality of cancer is changing because some cancers are becoming "chronic, lifelong conditions," according to the editorial, which was written by journal staff.

About 50% of cancer patients in the United Kingdom now have survivorship of at least 10 years after diagnosis, the authors report. Furthermore, the latest statistics from Europe and the United States reveal decreasing cancer-related mortality. Thus, there is need for "a shift in our perception of the disease and survivorship," they say.

The practice of oncology has changed cancer, agreed Jeffrey M. Farma, MD, a surgical oncologist at the Fox Chase Cancer Center in Philadelphia.

"We have transformed many cancers into a chronic problem rather than an acute problem that can lead to death," Dr Farma told Medscape Medical News.

Cancer is not a monolithic disease, he said.

Cancer is really a multitude of very different diseases.

"It is very hard for the public to conceptualize that cancer is really a multitude of very different diseases that are treated and behave in very different ways," he explained.

Dr Farma suggested that an enigmatic shame about cancer continues to linger among patients and the public. "It is, and will continue to be, difficult to overcome the stigma of the big C," he said.

Another clinician agrees. "We've gotten way beyond the time when cancer was one thing. But I am not sure that the big C has gone away," said Harold Burstein, MD, a medical oncologist at the Dana-Farber Cancer Institute in Boston.

I am not sure that the big C has gone away.

In his 20 years of training and practice, Dr Burstein has seen a "sea change" in the perception of cancer. "What has enabled that is real progress," he said.

The outlooks of cancers are now very different, thanks to advances in detection and treatment. For example, chronic myeloid leukemia used to have a very poor prognosis, but imatinib (Gleevec, Novartis) has dramatically improved 5-year survival rates.

Nonetheless, Dr Burstein said that a prominent metaphor used by patients, the media, and even clinicians does not help the perception of cancer to evolve.

"The battle metaphor is a uniquely American concept," he told Medscape Medical News. "We always expect that Americans will win. And, if you don't succeed, you lose."

This all-or-nothing mentality helps perpetuate the idea that cancer death is, more or less, a personal failing, said Dr Burstein. "People don't die after a valiant struggle with heart disease," he noted.

Another clinician echoed these thoughts.

William Dale, MD, PhD, a geriatrician at the University of Chicago, said that if the war imagery is dropped, then the focus can be on the person with cancer, "with the disease accepted as part of that person, rather than being seen as an invading enemy."

This acceptance is now increasingly common among men with prostate cancer, including those on active surveillance, and among older women with breast cancer, he said.

Currently, the public sees cancer as our most fearsome disease, Dr Dale observed. In a 2011 poll sponsored by the insurer MetLife, 41% of the American respondents reported that cancer was the major disease they feared most, 31% said Alzheimer's disease, and small percentages said other diseases.

The public, even sophisticated and educated laypeople, can have a starkly grim view of cancer, suggested Dr Farma. "Many friends have questioned how I can 'do what I do' every day," he reported.

How exactly the public perceives cancer is a subject that, surprisingly, has been understudied, said Kathyrn Robb, PhD, a psychologist at the University of Glasgow in Scotland.

However, in 2014, she and her colleagues conducted extensive interviews with 30 Scottish men and women without cancer, and qualitatively assessed attitudes.

Visceral fear of the disease is widespread.

"People appear to be of two minds about cancer. Despite recognition of the improvements in outcomes, visceral fear of the disease is widespread," she told Medscape Medical News.

"A rapid, intuitive sense of dread and imminent death coexists with a deliberative, rational recognition that cancer can be a manageable, or even curable, disease," Dr Robb and her colleagues wrote in their study published in BMJ Open (2014;4:e005434)

In fact, people often cite both points of view in one sentence, they reported.

Oncologists also have "high levels" of cancer fear, Dr Robb's team explained, citing an earlier study (Ann Oncol. 2003;14:57-61).

But societal fears about cancer might be in "transition," said Dr Robb, who cited as evidence two recent books about cancer that have been popular with the public (Siddhartha Mukherjee's Emperor of All Maladies and Lochlann Jain's Malignant: How Cancer Becomes Us).

The media can deeply influence public perceptions of cancer and survivorship, according to the editorial published in the Lancet Oncology, which cites, as an example, the New York Times column called Living with Cancer by Susan Gubar, a professor emeritus of English at Indiana University in Bloomington, who eloquently and unflinchingly discusses her ovarian cancer.

The various experts interviewed for this article strongly agree with this point about the media's helping change the perception of cancer.

However, Dr Dale made a subtle point. "I think the mainstream media is likely to reflect changes and spread them rather than drive those changes," he said. "It's even more important for the medical profession and the research community to adopt different attitudes and language surrounding cancer."

The persistence of the war/battle metaphor warps the reality of cancer into something that must always be vanquished — at any cost, Dr Dale said. It is a disease that can often be managed and often coexists with other morbidities as mortality risks in older patients, the age group in whom cancer is most common, he said.

Lancet Oncol. 2016;17:257. Editorial

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