A word-cloud generated from the text of this blog post
When famous people die of cancer, the media tends to be awash with military metaphors – he or she is said to have fought their cancer, and perhaps to have lost their battle with the illness. Since at least President Nixon’s ‘War on Cancer’ in 1971, it feels to me that cancer has become inseparable from the rhetoric of warfare. But as a poll by Macmillan Cancer Support has illustrated very well last week, many cancer patients feel uncomfortable and even disempowered by this military language.
I think it is time to give some serious thought about whether we are talking about cancer in the right way. It really matters what language we use to describe cancer, not only because we must always remain sensitive to the emotional responses of patients and their families, but also because our words shape the way we think about cancer and its treatment. Our words and images are important in how we think about the individual experiences of people who have cancer, and about the strategic challenge that researchers like me face as we aim to make the discoveries that will lead to more effective treatments for the disease.
I have spent the last 40 years researching novel ways of treating cancer. As a scientist and now as Chief Executive of The Institute of Cancer Research, London, I have often been concerned about the language we use to describe our research and our ambition to help cancer patients. I’ve come to the view that we need to strike a delicate balance between inspiring people to engage with our work, and showing sensitivity to cancer patients – some of whom dislike framing their illness as a battle to be won or lost. And we need to find the right words to convey our ambition for our research and our optimism for its ability to benefit patients, while also being candid about the size of the challenge we face.
A personal choice
During my career I have talked to many people with cancer, their family members, and doctors, about the use of military language. I have always been struck by how much opinion is divided – just as the Macmillan poll found.
On the one hand, there is the criticism that if we expect patients to fight against their cancer then they are somehow being judged or feel like a failure if they ‘lose the battle’. Some patients also find metaphors like this and other phrases such as ‘passed away’ euphemistic and prefer the simple phrase ‘died’.
On the other hand, it’s clear that some patients and their families do want to feel they are fighting against cancer and find the concept fitting and helpful for them. Supporters of organisations like the ICR can also find the concept of battling cancer useful and motivating. As with many things, it comes down in the end to personal choice.
The need for sensitivity
I myself tend to avoid aggressive military language when describing the experiences of patients with cancer. For patients who are terminally ill and have no effective treatment options, military clichés may be unhelpful, continuing to focus on aggressive fightback when the best approach might be to prioritise quality of life. I believe particular care is needed to be sensitive to and to take our lead from individual patients in describing their experiences with cancer.
I am generally more comfortable with the use of terms such as ‘battle’, ‘beat’ and ‘defeat’ to describe our overall strategic efforts as researchers to find more effective treatments for cancer.
At the ICR, for example, we are proud to state that our mission is to make the discoveries that defeat cancer. We find that form of words to be motivating for our staff and supporters, without I hope falling into the trap of characterising the experience of individual cancer patients as a battle or a fight.
But whether you feel such military language is acceptable or not, I do worry that it risks oversimplifying the whole endeavour of cancer research. It is too easy to talk about simply ‘winning’ or ‘losing’ against cancer – the reality will always be far more complicated.
Cancer is not a single disease
President Nixon was spurred on in his famous ‘War on Cancer’ by a hugely influential philanthropist called Mary Lasker. She understood the power of language and ambition to motivate people to a cause, and was a major player in persuading Nixon to increase funding to the US National Cancer Institute. But the promise of a cure for cancer in five years that she and Richard Nixon made to justify the investment was hopelessly over-optimistic.
They hugely underestimated the difficulty of creating new cancer treatments for what is not a single disease, but at least 200, each of them very distinct. Such a one-size-fits-all miracle cure feels even less likely now that we know that cancers are genetically diverse both between and within individual patients.
The problem with war as a metaphor for cancer research is that it can encourage the belief that we can defeat cancer through one concentrated campaign – and encourage false hopes of a single ‘magic bullet’ cure.
Alongside the military language of the War on Cancer, Nixon likened efforts to find a cure to a major Government engineering project – akin to putting a man on the moon. And there is no doubt that language like that can be highly successful at capturing the public’s imagination, which is why we saw such strong echoes of it when President Obama and Vice-President Joe Biden used the term ‘moonshot’ to describe their own renewed efforts to find a cure for cancer. The problem with describing cancer research in these terms, as a discrete, ambitious military-style operation, is that there is an inevitable backlash if the promised cure is not delivered in the years that follow.
Progress made but much still to learn
I think there have been multiple causes for dissatisfaction and the perception of failure. Curing cancer is not a military operation or an engineering problem but rather a huge scientific challenge – especially given cancer’s great complexity. It involves creative discovery research for which the outcome and timescales are difficult to predict. So Nixon definitely oversold and under-delivered, and there is always a risk that this could happen again.
Some of the criticism of the War on Cancer took aim at the use of aggressive, over-ambitious military language. Susan Sontag in her 1978 book Illness as Metaphor writes: ‘Treatment has a military flavour. Radiotherapy uses the metaphors of aerial warfare; patients are ‘bombarded’ with toxic rays.’ And she cautions: ‘With the patient’s body considered to be under attack (‘invasion’), the only treatment is counter-attack.’ So the risk is that aggressive treatments, featuring the highest possible doses of chemotherapy or radiation, could end up being favoured over subtler, kinder and perhaps more effective treatment options.
In 2004, a high-profile article in Fortune magazine declared that we were losing the War on Cancer. It argued that, while deaths from conditions such as heart disease were plummeting, cancer rates were as high as ever. I strongly disagree with its argument, as would most of the cancer research community. The reality is that we have made incredible advances against cancer in recent decades.
While we do still have much to learn, we have nevertheless gained an increasingly detailed and sophisticated understanding of the mechanisms by which cancers develop from healthy cells, and of the enormous complexity in how cancers adapt, evolve and become resistant to treatment. And that understanding has been translated into new treatments which are transforming outcomes for cancer patients.
Cures vs long-term control
Overall cancer survival in the UK is now double what it was in the 1970s, with over half of all patients surviving 10 years or more. On the other hand, survival in some cancers – such as those of the lung, pancreas, gullet and brain – is still very poor indeed. Less than 10% of patients with lung cancer survive even five years after their diagnosis. War tends to have a winner and a loser. With cancer, things are much more complicated.
But given that we are unlikely to escape military rhetoric completely, not least because of its popularity in the media, it is important to be clear about what ‘winning the war’ would look like. Vincent DeVita, a pioneer of early chemotherapy for cancer and former head of the US National Cancer Institute, says in his book The Death of Cancer: ‘I do…think we’re heading for a time when we’ll be able to cure all cancers. And those we can’t cure readily will be converted to chronic, manageable diseases.’ I agree with those views, but although progress has been rapid it will be incremental and will take time.
Within the scientific community there is some nervousness about using the term cure. There is debate about whether we should be aiming for – and talking publicly about – cures for cancer. Or whether it is more realistic to envision and discuss a future involving chronic, long-term control.
At the ICR, we do not shy away from stating that we are striving for cures for cancer, but we realise that in many circumstances long-term control may often be more within our reach in the immediate future.
Care is needed in our language
For many people with cancer the term ‘cure’ is tremendously important, and doesn’t only mean living the full length of life they would have had without cancer, but also being free of all cancer cells. Understandably, there is great value placed on being given the ‘all clear’, although in reality this means cancer cells cannot be detected, rather than necessarily that none are present in the body.
But for other cancer patients, being offered long-term treatment that will allow them to live with their cancer – such that they eventually die of another cause – will also be seen as a very acceptable outcome. Quality of life is also very important. So whether long-term control is regarded as a good result will depend on the level of side-effects of the treatment needed to achieve it.
I feel strongly that we should be able to talk about our aim to cure cancers without being accused of hubris or hype, although once again care is needed in our language. Equally, aiming for long-term control does not mean a lack of ambition to achieve eventual cure. What is interesting is that whichever of these goals we articulate, the research we need to do to get there will be largely the same. We will generally need to pursue the same scientific approaches whether the aim is to enhance long-term survival or to achieve full ‘cure’. That’s perhaps not surprising given that, in my view, enhancing long-term survival is a route to eventual cure.
When we talk about what we are aiming to achieve with cancer, we should remember that we do not have a crystal ball – and should not set expectations too high. We need to be mindful that medical and scientific challenges are always tough to crack and that timescales for breakthroughs are extremely difficult to predict. How to do this, while still engaging funders, policy makers, people with cancer and the general public with our hopes for scientific research, is a challenge that we need continually to work on.
Communicating an inspiring vision for cancer research
So where does all this leave us? I hope the Macmillan survey will help to spark a frank and open debate about the language we use to describe cancer and our efforts to defeat it. We need to understand the impact of our words on the pathway of cancer research and care, and the extent to which it is judged a success.
And we need to develop a clear understanding in dialogue with the public of what cancer research is aiming to achieve, and of the uncertainties of science, if we are to avoid the mismatch between expectations and achievements seen since Nixon’s War on Cancer.
We now understand the size of the challenge cancer poses, through its ability to adapt and evolve, and become resistant to treatment. We are discovering new knowledge and achieving often dramatic advances in targeted drug treatment, immunotherapy and radiotherapy to meet these challenges head on.
To continue to make progress, we need to communicate a clear and inspirational vision for cancer research, but one that is realistic, honest and respects the different perspectives of everyone whose life has been touched by cancer.
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