Cancer CareFebruary 6, 2014

Cancer is not war

By James Salwitz, MD

On December 23, 1971, President Richard M. Nixon signed the National Cancer Act of 1971, and declared The War on Cancer.  The allusion to combat appealed to the soul of the American people not long after their success in World War II and the humiliation of Vietnam; they intuitively understood the sacrifice, teamwork and massive effort, which is implied in the concept of War and they were ready for another victory.  Committing dollars, careers and dreams they charged to battle, with gusto just short of a ticker tape parade. Decades later the “battles” continue and perhaps one reason it frustrates us so is that at second look, defeating cancer is not armed conflict.

Leaders and fundraisers have done very well with the war analogy.  It rallies the troops, justifies military size budgets and commands conflict.  Seeing the disease as evil seems to explain suffering, as well as brutal treatment.  Doctors crush and destroy the enemy using aggressive therapy to target magic bullets, while motivating patients to fight.  We honor heroes and remember the fallen.

Nonetheless, despite the ability of “War” to focus our attention and amplify our goals, there is a problem with using this word, these feelings, this entire paradigm, to label cancer care.  Does it make sense to use a concept based on the deliberate slaughter of man as a synonym for healing? Is it fair to demand of patients that they be both soldier and victim, good and bad?  Their loss and suffering is not abstract like good verses evil, nor a theoretical struggle for ideas, which so often results in men taking up arms.  Theirs is a personal event of fear, loss, confusion and pain.  Moreover, critically, cancer, unlike war, is not about guilt.

War is about guilt.  However noble the cause in the history books, how glorious the battle, how important the victory, at the individual level, war is about guilt.  The brutal destruction of another human being can never be good, even if justified, and it can never be without terrible physical, emotional, and cultural loss, on both ends of the sword.  No warrior who shed another’s blood ever strolled from the battlefield with a smile on his lips and joy in his heart.  Everyone suffers for allowing it to happen, for what they have seen and what they have done. All share a deep guilt about their actions and the corruption, which can be man.

Treating disease is a noble and altruistic undertaking, which should not require guilt.  It is about individual patients trying to mend and return to their lives. It is about loved ones who support and suffer.  It is about nurses, researchers and communities who give care and work hard to find therapies. While it is about loss for all, it can also be about great achievement, great discovery and healing.  Have no doubt that when a new cure is discovered, or a CT scan is normal, men and women dance with a smile on their lips and joy in their hearts.

Like war, the memories linger for cancer survivors long after the event has passed. However, unlike war, cancer is no one’s fault.  When we label the quest for a cure as war, we imply that there are two sides in this battle and that there is guilt all around.  There is no evil in cancer, it is a malfunction of our bodies which can lead to loss and suffering; a disease which will soon be no more.  No one tries to hurt and humiliate another, only heal and give hope.  Cancer suffering causes enough anguish; perhaps it is time to leave battlefields behind.

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15 Comments

  • Mike
    Funny, I actually do think of my cancer cells as "evil," and I enjoy "taking out the sword" when it's treatment time. I feel no guilt in giving malignant cells the kick in the teeth they deserve for burdening me with their havoc.
    Reply
  • alyce
    The first time I was diagnosed with cancer, I felt like I should be Wonder Woman and get ready for the big fight. I needed to put on my armor and shield and go into battle mode. This is how I felt mentally and emotionally. Now after being diagnosed with breast cancer once more and a diagnosis of a Plasmacytoma in my spine I have developed Rheumatoid arthritis. I no longer battle mentally or emotionally. My Doctor and my body take on the challenge. I live my life with some pain but I do as much as I can. I am involved in several Church groups. I belong to a Book Club at my Library and I attend a tai chi class. Fighting cancer is something I am leaving to my Maker and my Doctor.
    Reply
  • Bridget Ryan
    Thank you for re-framing the approach. Having done the cancer diagnosis and treatment schedule twice in the last five years, I never embraced the battle mentality. Rather, I had to determine what things made sense and then show up, on time, ready for the compliance portion of the plan. None of it was easy nor pleasant, and the cheer leading affect from some of the technicians and nurses had to be addressed --- STOP IT, just treat me like a real person. I suspect my approach was too pragmatic for some, but getting through quietly, with as much of my true self present, was my aim. What I learned is that every person in the process has to define the process, the diagnosis, treatment, and aftermath, in a way to allow that person to cope. For some, the war metaphor seems apt, but it is not the only metaphor, and your essay provides another view. I think it would be helpful if physicians and the team actually asked patients how they are defining the process. That kind of discussion could be very helpful to everyone. I know, time is the issue, but this conversation would offer great clarity for both patient and medical providers.
    Reply
    • meyati
      said so very well. I differ with your last state-time is the issue- if this conversation was included in the early discussions. time would be saved. I was at my almost new PCP yesterday, and the discharge clerk wanted me to schedule a follow up then and there. I told him that I had to look at my calender-dentist, gyn, scan, 2 oncology appts, and dermatology-oh, I forgot the dog shots and their licenses. The clerk smiled and said--Tell so and so hello for me. I told him that I did not speak to these people and they hid from me. They wouldn't even run normal lab work for the surgery they proposed. The only place where I feel safe is the radiation clinic. It's the only place where I feel safe, and I'd treated well. I told him the regular clinic and these people wouldn't do any type of care, wouldn't get me another doctor, My PCP had to order the lab work that oncology wouldn't do. I didn't have any doctor to care for me after radiation ended. 5 days before radiation ended, I went up and said- get me a doctor- radiation is ending-this will make a good law suit-I'm complaining to the state board of health, etc. I've talked to the ACS about this, and this is their recommendation as writing letters, Emails, screaming and kicking the walls, etc. have not worked. So get me a doctor or get sued-- All of this went on because I didn't fight the war they wanted me to fight. I was told that I had a spiritual problem that I needed to fix, that I was mentally ill, emotionally ill, etc. I will add that patients and their care givers stood up and applauded me on one particularly violent day-- and said--It's time somebody stood up to them and told them the truth. I feel fairly safe with my new oncologist, when I'm in the office with him, but my BP goes up just being there. I joke that I ran off with the radiology clinic. I've been in remission for a year now-not bad for an aggressive, incurable cancer.
      Reply
      • Bridget Ryan
        Oh, I agree time would be better used if things were discussed. I'm just recalling how rushed I felt to sign things, decide this or that, make more appointments. It took my breath away, and then once done, I waited, waited, and waited some more. War and battle didn't work for me, nor did the Cancer as Gift framework, but I know many found these useful and helpful. For me, it was just a tedious, demanding, painful, lonely, and humbling process. A couple of people were truly helpful, and after several months, I finally found an oncologist who 'got' me and my perspective. Perhaps my metaphor is simply determination! All the best to you and to all of us in the oncology clinics --- patients and staff alike.
        Reply
    • D Someya Reed
      Bridget, you made me think of my wife for your perspective is one that she shared. She never liked the "war" metaphor. Neither did she consider her treatment a battle nor, had she come successfully through it, her continued existence to be always known as a "survivor." You are absolutely correct, in my opinion, that conversations need to be had between patients and their doctors. Cancer can't be pigeon-holed into "standards" of care or whatever. Not to minimize in any way your comments but I cannot remove this thought from my mind triggered by your "STOP IT." I just watched (again) Star Trek Into Darkness and your two words made me see the exchange between Kirk and McCoy when Kirk says, "And enough with the metaphors. That's an order!" There are some patients who want to be known as soldiers marching off to war. There are some, maybe more than you might think, that just want to quietly get well again or regain what life they can. The "war" is really more to separate you from your donation dollars. Another conversation we need to have is how and how well have, are and will those dollars be spent. Cancer dollars should not be wasted to anywhere near the same degree as they are in "real" wars.
      Reply
      • D Someya Reed
        I posted my reply before I saw yours, Bridget, with the "I finally found an oncologist who ‘got’ me and my perspective" comment. That is exactly what Jodi said was of utmost importance about every single doctor and not only just for her but also that each of them "must get us." We were a team and no one escapes cancer unscathed whether you were the one diagnosed or not. There are no good metaphors for cancer. It simply needs to be gone.
        Reply
        • Bridget Ryan
          You sound like quite the team, and I am glad she had you with her every step of the way. Amen to your notion of being well and truly gone.
          Reply
  • Jim Clear
    Wow.....how elegant and simple the truth can be told. I am now a bodyworker, one who has tried to touch the person, (the whole person), body-mind-spirit, for the past three decades. I moved from my formal training and practices into an integrated practice that supports those with cancer at any stage, that recognizes healing may come in many forms, that there is no one way to address life, disease, or healing. As a veteran I agree, war is about guilt, loss, and shame for some of us. We need to choose our words, our actions, and healing with art as well as science.....Dr. Salwitz blog has become a favorite....I hope he continues to speak for a long time.
    Reply
  • Karen D. DeCuir- DINicola, Principal- WaitWell
    Dr. Salwitz, thank you for this insightful post. As a two time cancer survivor, I can tell you it was a gift, not a war. It helped me get my mind, body and spirit where it needed to be for total health. I believe an illness such as cancer, or any DIS ease in the body can be used for healing all that ails us. Don' misunderstand, healing doesn't always come in the form of cure, what I have experienced is a vastly improved perspective on life, health, balance... you name it. Ironically for me, I will live a longer, more fruitful life because of cancer. I have dedicated the 2nd half of my life to helping others engage waiting time, whether in the healthcare environment, or outside of it... between appointments to take an active role in their health and healing. So much can be done by the patient that will help doctors, like yourself, to improve the healing journey. Thank you for your previous post as well on being a caretaker, while I haven't had the intense experience that the subject of your post had, it does strengthen me to have your inspirational perspective about some of the less attractive things I must do as a caretaker. All the best and God Bless you for the work you do!
    Reply
  • D Someya Reed
    This is a very lovingly written post about an unloving subject but I have to disagree with the use of all the absolutes. War is no more "always" about guilt than no doctor ever having experienced guilt for causing the suffering of a patient he/she was attempting to cure. There ARE some people who've walked off a battlefield with that smile and joy. We might call them deluded or delusional but there are some who are that certain in their convictions. We can't say that cancer is no one's fault then turn around and say "don't smoke," "don't eat too much sugar," don't do this, don't do that or you'll increase your risk of cancer. What kind of mixed messages are we sending when that person who didn't listen ends up with cancer. Are we then going to tell them "It's not your fault?" Even worse is when we (and by "we" I'm referring to the media) tells us that, for instance and my first personal recollection of this, that tomatoes have been found to cause cancer. But, they add, you'd have to eat 8 truckloads a day for a year in order to accumulate enough of (whatever carcinogen they contained) for you to get cancer. Does anyone else see the problem? So for the past two days, I have been seeing and reading about a study by the WHO (World Health Organization) that is claiming to project a 57% increase in cancers worldwide or some 22,000,000 new cases per year within the next 20 years. Some say we're making progress, some say the war continues. You say "a disease which will soon be no more." I REALLY want you to be right! And on that day, when neither of us have anything more to do, I'll hope to challenge you to a game of chess in the park. And here's a tip: I stink at chess.
    Reply
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  • joannevalentinesimson
    I so agree with you that we should abandon military analogies when it comes to talking about, treating, and living through cancer. Or any other disease, for that matter. Toward the end off your post, you say that cancer is "a disease which will soon be no more." What can you possibly mean by that? Is this at the individual level, when it is either cured or the patient dies? Cancer, as a condition of cells gone wild, will always be with us, because our cells "misbehave" from time to time and replicate without control. This is more common in the very young and in the elderly, and as we have many more elderly, now, this disease (actually many different types of disease, as you know) will continue to increase in the population. People cannot live forever (let's hope), and if they are not killed by germs or accidents, their own bodies will eventually sabotage them.
    Reply
  • IBS
    Well, I can say tomorrow will be two years as a palliative patient having stage4 lung cancer and another few things. Spiritually, don't give up.
    Reply
  • Brian Gill, MSW-C
    This is thought-provoking. Medically, I want researchers to spare no effort in defeating (a war-like term) diseases such as cancer. However, clients/patients I work with often need to figure out their relationship with their disease. Dying is not about losing a war or being defeated. Their needs to be detente in this highly personal journey. Thanks for the insight.
    Reply

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