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Misguided Metaphor

Harpham, Wendy S. MD

doi: 10.1097/01.COT.0000285398.81809.0c
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“How can they say that? Of all people, they should know better!”

I excuse elderly people, realizing they remember when cancer was “the Big C” and patients didn't have much chance. I forgive young adults, too, assuming their naiveté about terminal illness. But when a respected national organization—especially a survivorship group—announces that so-and-so “lost her battle” with cancer, I explode.

The battle metaphor doesn't work well for me as a patient, but that's not the upsetting part. It's this notion of losing.

To lose means to give up or otherwise fail to win a match of wits, brawn, or nerve. Whether on a sports field, in an artillery zone, or at a tribal meeting of television's Survivor, to lose your battle means you've been defeated. Someone else won, and you lost.

In some battles, the outcome depends purely on the combatants' talents, decisions, and efforts. In other battles, luck plays a crucial role. What about cancer?

My doctors beat my original lymphoma into remission with “big guns” chemotherapy and bombarded my first recurrence with radiation. Through it all, I armed myself with good nutrition, exercise, prayer, support group, and a positive attitude.

Soon after being diagnosed with my second recurrence, I screamed to the sky, “What am I doing wrong?” Hearing such an absurd question escape from my own mouth shocked me into realizing the only thing wrong was how I was thinking about my disease.

As a physician, I had intimate knowledge of illness as intrinsic to the human condition, along with pain, loss, and awareness of our mortality. I knew that my battle—if we must call it that—between me and my malignant cells would likely determine the number of my days. But the important battle ahead was that which would define me as a person: namely, the fight to find courage, fortitude, wisdom, and patience in hard times. The human struggle after cancer lies in creating meaning and joy in whatever time we have.

Metaphors serve a useful function, clarifying ideas and motivating people with graphic visuals. The declaration of a “War on Cancer” in 1971 helped funnel government funds toward needed research. And every day, personalized “battle plans” have encouraged many newly diagnosed patients to get second opinions, consider clinical trials as treatment options, eat healthful diets, and ask for emotional support. Clearly, battle imagery can nourish hope and prompt effective action.

So why do I get worked up about “lost her battle”? Because in the context of end-stage illness, this metaphor is seriously flawed in two ways.

First, no victor emerges from the battlefield of hospice. Disordered sheets of cells with bizarre nuclei don't stand on podiums with gold medals around their surface antigens; malignancies—now powerless—are buried.

Second, and far more important, is the harm this metaphor does to patients in their final days and to their loved ones left behind. Dying does not mean a patient has lost.

The first century Roman writer Marcus Seneca said, “Fire is the test of gold, adversity of strong men.” Before my cancer diagnosis, I saw myself as a doctor, wife, mother of three, mediocre violinist, and terrible humorist. Yet it was only after cancer, when I was sick and bald, or closing my medical practice, or gearing up for yet another round of treatment, that I discovered essential truths about myself.

To say that a patient who died has lost the battle is to insult the memories of people that inspire me today. Ellen, Lloyd, and Nancy are only three of my many friends and acquaintances who nobly faced illness and death, each with a unique blend of hope and acceptance, humor, humility, fire, and grace. Cancer failed to rob any of them of their dignity and humanity.

When you hear that someone died of cancer, all you know is that he or she died.

The person who dies of incurable disease or some complication of treatment, but who obtained good medical care and connected lovingly with friends and family to the end, has triumphed. The person who is cured, but who lives with bitterness about aftereffects or in constant fear of recurrence, has succumbed.

For me, triumph over cancer is measured by how you live, not how long. Put another way, what matters is what you live for, not what you die of.

And take this warning: If anyone writes in my obituary that I lost my battle with cancer, I am coming back!

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