When talking about cancer, metaphors matter

Cancer is hard to talk about. It’s serious, often frightening, and complicated. So, as with many complex topics, we often turn to metaphor. In discussions of cancer, metaphors are rampant. One in particular — that of a fight — is especially common.

She’s battling cancer
He’s putting up a real fight against his disease
You can beat this

Almost five years ago, someone I’m close to was diagnosed, and I started to realize how inappropriate this language felt — at least for this particular case I was witnessing. There was no fighting. There were bed-bound days, invasive procedures, and sympathy cards. One might say that just showing up to every appointment — especially those where you know you’ll feel terrible afterwards — is fighting, but that’s not how it looked to me. So I started to wonder: how does this pervasive “fight” metaphor affect the way we think about cancer? Are there better alternatives?

I was intrigued to find that I wasn’t the first who had asked these questions, and that there’s actually a substantial field of research on language related to illness. There were also articles in popular media, which would pop up without fail each time a famous person was publicly diagnosed with or died from cancer. People were not only using fight-related language to talk about cancer (e.g., Ruth Bader Ginsburg v. Cancer), but they were also questioning whether that language was appropriate (John McCain did not ‘lose’ his battle with glioblastoma — because cancer is not a war) and offering up alternatives (Cancer is a Journey, not a Battle).

But for all the interesting research and commentaries that were out there, I still wanted empirical evidence. When someone talks about “fighting a battle” with cancer, how does that affect the way we think about the illness? And if “battle” is a harmful metaphor, is “journey” better, as is often suggested?

Together with my collaborators Zsófia Demjén, Elena Semino, and Lera Boroditsky, we ran some experiments to learn more about the ways that “battle” and “journey” metaphors affect emotions and thoughts about someone who has cancer.

We learned that when people are told that someone is battling cancer, they predict that the person will be less likely to make peace with their situation and more likely to feel guilty if they don’t recover — because they should have “fought” harder.

We found this by running 5 experiments with a total of 1,629 participants. Every participant received a paragraph that talked about someone battling or someone on a journey with cancer. Aside from the metaphor, these passages were the same, and all participants indicated their agreement with the same two statements after reading:

  • He* will feel guilty that he hasn’t done enough if he does not recover.
  • He can make peace with his experience.

The fact that participants believed that someone battling would be more likely to feel guilty and less likely to make peace should give us pause. These are not optimistic beliefs and may not be conducive to healing.

But it’s also crucial to remember that this was an effect averaged over a lot of participants. It does not tell us that the battle is pernicious for all people in all cases. There may very well be people who prefer the battle metaphor, who feel energized and motivated by it, and who feel it most accurately captures their situation. But that’s a decision for people with cancer to make.

It’s not a decision for doctors, journalists, researchers, or even close family and friends to make. We should not impose our language on people with cancer (or any other illnesses, for that matter). If their experience is a battle, it’s a battle. And if it’s not a battle to them, we should not call it one.

The most important take-away for me, then, is not that we should use one metaphor and not another. It’s that metaphors are powerful tools, and we need to be thoughtful about how we wield them.

Here’s the link to the full paper. Please cite it as: Hendricks, R.K., Demjén, Z., Semino, E., & Boroditsky, L. (2019). Emotional Implications of Metaphor: Consequences of Metaphor Framing for Mindset about Cancer. Metaphor and Symbol, 33(4).

Featured image by Timothy Eberly on Unsplash

*In all studies except one, the subject of the paragraph was a male. We did this so we could most clearly understand the effects of the metaphor when all other characteristics of the information were the same. We did explore gender in one study (Experiment 4 in the paper posted above), but a lot more should be done to understand how the ways in which identity might interact with the effects that metaphors have on thinking about cancer.

Battling cancer or…?

I’ve been thinking a lot about how we talk about cancer (and illness more generally) over the past few months, one metaphor seems pervasive, almost inevitable: cancer as an enemy that we battle. We say that someone is fighting cancer, and eventually every patient will either beat it or lose his battle to cancer.

Luckily, there’s been some research on the cognitive consequences of using the battle metaphor. This article by Charlie Cooper talks about work by Elena Semino (which I’m having trouble finding). He writes that her work shows negative effects for many cancer patients when their disease is framed as an enemy to battle. It doesn’t seem surprising that this metaphor might encourage people to feel personally responsible if their health worsens. Semino does say that the metaphor isn’t necessarily harmful, though – if a patient introduces it on his own, it might be a motivator. Semino and her colleagues also found that cancer is often talked about as a journey. For example, living with cancer might mean being on the hard road. This metaphor seemed less potentially harmful, instead instilling a sense of companionship among people with cancer. The conclusions about the effects of both metaphors are based on corpus analyses, so it would be very cool to see a lab version that examines the different inferences people make about the disease when it’s framed as a battle versus a journey.

Image: http://www.cancerhealercenter.com/blogs/how-india-is-showing-the-world-a-way-to-fight-cancer/
Image: http://www.cancerhealercenter.com/blogs/how-india-is-showing-the-world-a-way-to-fight-cancer/

I did find one lab study by Hauser and Schwarz on the war metaphor for cancer, but it examined the effects on healthy people, as opposed to those living with the disease. Specifically, it looked at how framing the disease as an enemy to be fought affects people’s preventative behaviors. A number of behaviors are associated with cancer – unhealthy diet, excess sun exposure, and smoking, for example. The authors distinguished between limitation cancer-associated behaviors (things like limiting unhealthy foods) and engagement cancer-associated behaviors (things like be lean and engage in exercise). The first category contains things we should do less of, and the second contains things we should do more of.

The researchers found that when cancer was framed as an enemy, people could think of fewer limitation behaviors, and in a separate study when given the limitation behaviors, they reported less of an intention to limit these behaviors. They report that these findings are consistent with the metaphor because when we’re fighting an enemy, our priority is on attacking, as opposed to limiting certain behaviors. Thus we might expect that the enemy metaphor increased people’s intentions for engagement behaviors, but this was not the case. Further, they found that when they reworded the limitation behaviors to sound more like engagement behaviors, people were more likely to induce them if they had read that cancer was an enemy, suggesting that they avoided endorsing those same behaviors earlier because they were framed as limitation behaviors, and reading the enemy metaphor did not put people in a limitation mindset. Since referring to cancer as an enemy reduced people’s likeliness of following important limitation behaviors and did not affect their intentions for engagement behaviors, the authors conclude that the metaphor seems to bring more harm than good.

I’m excited by these preliminary results, and I’d love to see more. Are there other metaphors that might be more productive? How do these metaphors affect people with the disease? Do they affect a person’s treatment decisions? We wouldn’t need to test this on cancer patients, necessarily, but could ask healthy participants to imagine they had the disease and reason abut it accordingly. How do the metaphors affect cancer patients’ caregivers? One difficulty in addressing these questions is that whether people are exposed to the enemy metaphor or not in a lab study, they’ve almost definitely been exposed to it many times outside the lab, and those prior experiences will follow them into the lab. Regardless, the general question of the cognitive effects of disease metaphors seems to be an important and addressable question.

In my own conversations, the enemy metaphor didn’t seem appropriate in a lot of contexts – lots of patients go to doctors’ appointments and cope with treatments and side effects, all of which are unpleasant but might not really involve fighting (in fact, minimal fighting seems to be the ideal). Surely, living with cancer requires a lot of mental toughness, but many things require toughness that we don’t talk about as battles (like earning a PhD, for example – I don’t think we’d say that the average person battles grad school). Even the journey metaphor, which Semino’s team found in corpora, seems a little weird. So if we think the battle metaphor is harmful, what’s a better way to talk about the disease?