“More than conquerors”: a qualitative analysis of war metaphors for patients with cancer

Abstract

Purpose

Meaning-making is fundamental to the cancer experience and communication within cancer care is saturated with metaphors. The objective of this study was to better understand the impact and function of war metaphors among patients with cancer.

Methods

Patients at the Duke Cancer Center were purposively sampled for inclusion based on type and stage of their cancer. Each patient underwent a semi-structured interview to explore their use of metaphors in their lived experience with cancer. Qualitative interviews broadly explored two key areas of interest: (1) frequency and use of metaphors to describe cancer diagnosis, treatment, or survivorship; (2) function and impact of the war metaphor on the patient experience of cancer.

Results

Fifteen participants with either breast, lung, or colorectal cancer were interviewed. Most patients used metaphor themes of journey, war, and mystery to describe their cancer. All patients with non-metastatic disease used war metaphors and described how these metaphors facilitated meaning-making by promoting positivity and situating cancer within a larger life story. The few patients who did not use war metaphors had metastatic disease, and they explained that war metaphors were unhelpful due to feeling a lack of control over their metastatic disease and outcomes.

Conclusion

The war metaphor should remain an integral part of cancer care. Disregarding war metaphors robs patients of an important framework for meaning-making—one that may promote strength, continuity, and resilience in navigating cancer.

Background

Each year, 1.9 million new cases of cancer are diagnosed and 609,000 people die from cancer [1]. For patients with cancer, meaning-making is fundamental to their lived experience and communication within cancer care is saturated with metaphors [2, 3]. These metaphors function as an important expression of the illness experience.

Metaphors can evoke characteristics of an experience that enable coping and a shared reality between patient and clinician [4]. This discourse has been studied in palliative care, infectious diseases, and oncology [5–8]; these studies affirm that metaphors are pervasive in our thinking and can serve both therapeutic and harmful roles. Some authors have suggested that by understanding the role of metaphors in the patient experience, clinicians can (1) improve communication and prognostic awareness, (2) better anticipate difficult decision-making conversations, (3) increase trust in the patient–clinician relationship, and (4) palliate patient symptoms early [9–11].

Existing work pertaining to metaphor use in oncology is limited and does not adequately address the patient perspective through rigorous qualitative analysis [12–16]. War-oriented metaphors are among the most commonly used and discussed [17, 18]. Therefore, the objective of this study is to better understand the impact and function of the war metaphor for patients with cancer. Through semi-structured interviews of patients with varying stages and types of cancer, we aim to describe the role of the war metaphor in their illness experience.

Methods

Eligibility and enrollment

This study received approval from the Institutional Review Board at Duke University School of Medicine (IRB Pro00107967). Patients at Duke Cancer Center who had been diagnosed with lung, colorectal, or breast cancer within 12 months of study start (August 2021) were contacted for enrollment. These cancer types were chosen based on existing research in supportive care for these populations [19–27]. Further eligibility criteria for patients included having an active treatment plan (radiation, hormonal therapy, immunotherapy, or chemotherapy) and being at least 18 years of age. Patients were intentionally sampled for diversity in stage of cancer and treatment goals (e.g., early, curative intent vs. metastatic, noncurative intent). Patients who had not received treatment within the previous 2 months or without plans to receive treatment in the 2 months post-interview were not contacted. Patients who met criteria were given the opportunity to provide written consent. If consent was given, the participant completed one 30-minute interview at their convenience.

Data collection

The semi-structured interview guide (Supplement 1) was developed and iteratively refined around two key areas of interest: (1) frequency and use of metaphors to describe cancer diagnosis, treatment, or survivorship; (2) function and impact of the war metaphor on the patient experience of cancer. As part of the interview, patients were also given a list of metaphors with option to comment on any additional metaphors. This list was synthesized from the following two sources: (1) existing literature on oncology metaphors and (2) reflections from the Duke Cancer Center’s social workers and patient navigators who had exposure to cancer support groups. Interviews were conducted by MHB. They were virtually performed and recorded using a Duke-approved secure video software.

Metaphor theory and its implications for data collection

Conceptual metaphor theory, which was popularized by George Lakoff and Mark Johnson in Metaphors We Live By, guides this study’s analysis. Lakoff and Johnson define metaphor as “understanding and experiencing one kind of thing in terms of another” [28]. Metaphor is embedded in the very thought processes and culture of the system in which we live. In an example about ‘argument as war,’ Lakoff and Johnson show that even without explicit use of the ‘war’ metaphor, one might conceive of and execute arguments in a combative fashion. Verbs and nouns can describe a figurative posture toward a life event, and this forms an implicitly metaphorical framework. Therefore, metaphors are not isolated nor quantifiable: “No metaphor can ever be comprehended or even adequately represented independently of its experiential basis” [28]. This poses a promise and challenge for qualitative analysis of metaphor. Hence, to analyze metaphor as an implicit template for the cancer community while accounting for its individualized function for each person living with cancer, we took seriously the ambiguity of metaphor, preferencing the “perceptions and inferences that follow from it and the actions that are sanctioned by it” [28]. To account for the experiential basis of metaphor, this study used semi-structured interviews which extended focus beyond the occurrence of metaphor.

Qualitative analysis

Interviews were transcribed verbatim (MHB and NCD) and imported into the NVivo 12 software (QSR International, Melbourne, Australia) to facilitate organization and content analysis [29, 30]. Three investigators (MHB, NCD, TWL) developed a codebook through cycles of open and axial coding. This codebook was used to code all transcripts from August to December 2021. The codebook was also refined continually as themes emerged. The analysis team, composed of healthcare professionals and qualitative researchers, engaged in comparative discussion of findings to resolve coding discrepancies and ultimately collated codes into a representative list of themes and quotes after reviewing 15 transcripts.

Results

A total of 48 patients were eligible; 25 patients (52%) enrolled, and 15 patients (60%) completed semi-structured interviews. Reasons for declining participation included fatigue secondary to chemotherapy and inability to access a computer for consent/interview. Of the 15 patients who enrolled, the mean (standard deviation) age was 59.6 (12.6) years, 9 (60%) were female, 11 (73%) were White, and there were equal (n = 5, 33%) numbers of participants diagnosed with breast, colorectal, or lung cancer. Participant characteristics are further described in Table 1.

Table 1.

Characteristics of participants (N = 15)

Characteristic	Mean	SD
Age	59.6	12.6
	N	%
< 60	6	40.0%
60 +	9	60.0%
Characteristic	Mean	Range
Months since diagnosis	5.6	1–11
Characteristic	N	%
Gender
Female	9	60.0%
Male	6	40.0%
Race
White	11	73.3%
Black or African American	3	20.0%
Other	1	6.7%
Ethnicity
Hispanic or Latino	0	0.0%
Religion
Christian (such as Protestant, Orthodox, Catholic)	10	66.7%
None	3	20.0%
Other	1	6.7%
Prefer not to answer	1	6.7%
Partnered status
Married or partnered	13	86.7%
Divorced	1	6.7%
Single	1	6.7%
Widowed	0	0.0%
Dependent children
Yes	8	53.3%
No	7	46.7%
Income ($)
Less than 50,000	3	20.0%
More than 50,000	8	53.3%
No response	4	26.7%
Insurance status
Insured	15	100.0%
Education level
Doctorate/medical degree/law degree	1	6.7%
Master’s degree	3	20.0%
College graduate	4	26.7%
2 years of college/AA degree/technical school	3	20.0%
High school graduate or GED	1	6.7%
Prefer not to answer	1	6.7%
Cancer type
Breast	5	33.3%
Colorectal	5	33.3%
Lung	5	33.3%
Cancer stage
Non-metastatic	8	53.3%
Metastatic	7	46.7%
Treatment type
Chemotherapy	10	66.7%
Immunotherapy	5	33.3%

Metaphor categories

The most used metaphor categories were (1) journey or nature (e.g., season), (2) war (e.g., battle, victory, fight), and (3) uncertainty (e.g., mystery, puzzle). These categories of metaphors are listed in Table 2, with representative quotes of the metaphor-aided conceptualization of cancer.

Table 2.

Describing cancer using metaphor

Metaphor theme	Description of cancer as:	Quotes
Journey	Requiring preparation	“It’s how I take care of myself during the journey; drink water, keep on doing the exercises to minimize the side effects. That’s part of the journey that will help me be on the right side of the journey.” (ID 1)
	Habitual and chronic	“So this will forever be a journey, you know. Where I will end up in the journey, nobody knows. So it will always, forever, be a journey—every time I go get a mammogram or an ultrasound, that’s part of the journey, that’s a stop in my journey.” (ID 1)
	Leading to personal growth and identity change	“Everything has a time that it will end, and at that time that it ends, you’re gonna find yourself on a new journey. That journey is gonna govern the remaining part of your life, because that journey is gonna help you live a better life. (ID 2)
	Unpredictable	“But I would tell them, start documenting your journey, because this journey is gonna take you through a lotta ups and it’s gonna take you through a lotta downs. That’s one thing—it’s a journey.” (ID 1)
Nature	Temporary	“This is not my whole life, it’s a part of my life, a season of my life that will pass regardless of if it goes terribly bad and I pass away—God forbid—it is still not the entirety of my life. I had 38 years up to this point of my life.” (ID 3)
War	Ascribing cancer treatment to a battle	“If you don’t completely kill everything, then it actually gets stronger. They used the philosopher’s name, Nietzsche, in that paper they quoted him saying, ‘The thing that doesn’t kill me, makes me only stronger.’ So when you’re treating cancer, you’ve got to completely eliminate.” (ID 4)
		“And I think a person is gonna battle that a lot, maybe not every day, but a lot—trying not to get lost in it. That it just consumes you. You can’t let it consume you—it can… you can let it consume your entire life.” (ID 5)
		“I know that now I am on a journey where I am a conqueror of cancer.” (ID 2)
	Perception of God’s power and strength relative to cancer	“Because when you hear the word cancer, people think that that C is bigger than the G. But God is bigger than everything, and God can fight cancer and has fought cancer. So cancer isn’t bigger than the God that I know that I serve.” (ID 2)
Uncertainty	Unpredictable	“So I did a lot of work, a lot of reading on this material. So in that sense, it’s like a mystery. Because there’s so much information out there, but still there’s no cure that is applicable to all the people. It works for some people, it doesn’t work for others, and so on. In that sense, we did a lot of reading and thinking about this. It’s like a puzzle.” (ID 4)

Metaphors were often used in conjunction with one another with varied meaning for the individual. As seen in Table 2, different metaphors could be used to describe cancer in a similar way. For example, cancer’s unpredictability was narrated as a ‘journey’ (“This journey is gonna take you through a lotta ups… and a lotta downs”) and a ‘puzzle’ (“There’s so much information out there, but still there’s no cure that is applicable to all the people… It works for some people, it doesn’t work for others… It’s like a puzzle.”). Most patients (11/12) who used war metaphors also used at least one other metaphor to describe cancer. Even within categories, descriptions of cancer were incongruent; the function of the same metaphor differed based on context and patient experience. For example, two patients used ‘journey’ to communicate the identity change associated with cancer (“You’re not gonna be the same person that you were before you heard the word cancer… I’m on a new journey, because I know that now I am on a journey where I am a conqueror of cancer.”) as well as the habitual chronicity of treatment (“It will always, forever, be a journey—every time I go get a mammogram or an ultrasound, that’s part of the journey, that’s a stop in my journey.”).

Function of war metaphors

Since many patients report war metaphors [17, 18], we focused on this category for the remainder of analysis. Almost all patients with non-metastatic disease (7/8) and the majority (5/7) of patients with metastatic disease used war metaphors to describe their cancer experience (Table 2). Through this, cancer was imbued with violent characteristics: “If you don’t completely kill everything, then it actually gets stronger” and “It just consumes you. You can’t let it consume you—it can.” In addition, cancer was named as enemy, with the body caught in crossfire: “God can fight cancer and has fought cancer. So cancer isn’t bigger than the God that I know that I serve” and “Chemotherapy is poison… [it] destroys other organs or tears down other good cells in order to affect the bad cells.” War metaphors were frequently referenced in patients’ support communities (e.g., religious congregation, family/friends, military affiliations); only one patient noted the reference to war metaphors by their clinician.

In addition to plain description (Table 2), war metaphors served a multivalent purpose in patients’ cancer experience (Table 3). Within a war framework, patients viewed themselves or a higher power as the fighting warrior, encouraging them to persist despite the adverse effects of treatment: “Because [my children] were [saying] ‘we’re not worried because we know that you’re a warrior, and that you’re gonna succeed at this.’” War metaphors also echoed previous life struggles, instilling confidence to overcome the cancer diagnosis: “I’ve been fighting all my life. I feel like one more fight won’t make a difference… I’m gonna fight and I’m gonna beat cancer, and I did.” Taken together, war metaphors led to a spectrum of role- and meaning-making strategies that empowered patients with cancer.

Table 3.

Functions of war metaphor in patient narratives

Theme	Quotes
Related cancer to previous life challenges	“Because I’ve been fighting all my life. I feel like one more fight won’t make a difference. And growing up as an African-American child living in poverty and living in a household where there was 7 children, we’ve had to fight. We’ve had to learn how to survive. So, fighting cancer is learning how to fight. Because I had that tool of learning how to fight, one more fight won’t make a difference. I’m gonna fight and I’m gonna beat cancer, and I did.” (ID 2)
Expressed optimism	“Most of the people I’ve met, other patients, especially the team there at Duke, that they are positive—they’re talking about ‘winning the battle.’ They’re not talking about losing, not winning. And I mean that’s awesome, I think that’s a lot of the battle right there.” (ID 5)
Promoted perseverance in the face of adversity	“It [“Warrior”] was used when I was speaking with my children. Because they were also, kind of, saying the same thing, like “we’re not worried because we know that you’re a warrior, and that you’re gonna succeed at this,” and everything. I was trying to build confidence in them that, with God, we will prevail, and you know, we will get over this.” (ID 6)
Renewed strength through transferal of agency to God	“I feel that God is in control of it. And even though I call myself a warrior, I feel like He is the greatest warrior and He’s the one that is pulling me through the process.” (ID 6)

Against war metaphor

Among all patients who used metaphorical language to describe their cancer experience (n = 14), the two who did not use war metaphors had metastatic disease. First, a father to young children who was newly diagnosed with metastatic colorectal cancer shared that due to his upbringing of “practicalness”on a rural farm, he always preferred plain language over metaphors. He noted that war metaphors misrepresented his cancer experience as follows:

1. Inaccurately conveying a sense of cure or temporariness: “I don’t need a wristband to remind me that I have cancer. There’s never going to be a day in my future that I don’t remember that I have cancer… The idea of survivor—I'm, nowhere close to being a cancer survivor at this point in time. The chemo is working great, the tumors are shrinking rapidly, my CEA number is back down to the normal range. But, I assume if we stopped chemo today, that the tumors would wake back up and start growing again.”

2. Assuming a false sense of agency: “If you go sit in the waiting rooms and look around, I don’t see warriors sitting in the waiting rooms. Right? Like if somebody is a warrior, they’re fighting, right? I’m not really fighting the cancer, because I’m not changing much about my lifestyle. I’m taking chemo and the chemo is fighting the cancer.”

3. Implying a loss or death: “If I look at militaristic—what am I fighting? I’m fighting the part of my body and at the same time I’m fighting my whole damn body, really. I take chemo, it kills everything and it’s killing the stuff that’s not supposed to be there, but it’s also killing the rest of my body”.

4. Demanding a continuous optimism: “I’ll tell people flat out that it sucks. Don’t get me wrong, I lied to people for the first few months, always telling them ‘It’s okay, we’ll get through it.’ I started getting mentally worn down by it to the point now, that when somebody asks me, that’s my first response. Like, ‘How’s cancer, how are you doing?’ I’m like ‘man, it just sucks.’ And then we’ll get deeper into ‘How does it suck? What does it feel like?’”

5. Glorifying the ordinariness of cancer treatment: “My job as the cancer patient—one of my jobs—is to drink water, to stay hydrated. That’s not a fight, that’s just a job that has to get done.”

Second, a 56-year-old patient with a recurrence of breast cancer after several years of remission, shared that although her clinicians only used “matter-of-fact” language, her “well-meaning support group” frequently expressed support through war metaphors. To her, this rhetoric showed a “lack of understanding of what was going on.” Like the patient above, she found that war metaphors framed cancer in the following ways:

1. Implying a loss or death: “It implies that if—especially with stage four—if I were to die, which I most likely will, then I’m a failure, I’m weak, I’m not a good fighter.”

2. Assuming a false sense of agency: “It’s been unhelpful the whole time [before and after metastasis] because all along the way I explained it to my husband is I never really felt like a warrior, I felt like a battlefield and the doctors were the warriors, and they were pretty good at it.”

Discussion

We used semi-structured interviews of 15 patients with either breast, colorectal, or lung cancer to better understand the impact and function of the commonly used war metaphor for patients with cancer. We had three main findings in this study. First, most patients used metaphor themes of journey, war, and mystery to describe their cancer. Second, in a focused analysis, the majority of patients used war metaphors, as these facilitated meaning-making by promoting positivity and situating their cancer within a larger life story. Lastly, the few patients who did not use the war metaphor found this metaphor unhelpful due to feeling a lack of control over the outcome.

Given the abundance of metaphors in lay cancer discourse [2, 3], it was not surprising that we saw patients frequently use metaphors to describe their cancer diagnosis. Patients identified metaphors that evoked characteristics of cancer and allowed them to better understand their cancer diagnosis; for example, metaphors of journey and season were frequently used to normalize the chronicity of disease, while metaphors of puzzle and mystery helped patients cope with the unpredictable, tortuous path of treatment decisions. Metaphors are a substantial part of patients’ frameworks as patients approach diagnosis, treatment, and survivorship. The versatility of metaphors can be a crucial tool in patient communication and decision-making [9–11], so clinicians should be open to exploring the multitude of metaphors [31] that can enable meaning-making in the cancer care experience.

There has been a call in the literature to dispose of war metaphors in cancer discourse [12, 14, 15]. However, in this study, most patients used the war metaphor to both describe their cancer and cultivate an optimistic outlook in their illness and treatment experience. Although we did not specifically explore positive psychological wellbeing constructs (e.g., optimism, perseverance) which have been associated with important clinical outcomes in various oncological populations [32, 33], war metaphors seemed to facilitate meaning-making and positive psychological wellbeing, suggesting a possible relationship between war metaphors and coping strategies. Existing literature has underscored the role of approach-oriented coping strategies (e.g., positive framing, problem-solving, utilizing emotional support) in improved psychosocial outcomes [34–38], increased prognostic awareness [39, 40], and as a mediator of improved patient-reported outcomes in palliative care interventions [41]. War metaphors have been previously shown to have different coping effects based on their object of ‘defeat’ or ‘fight’ [42]. In this study, patients similarly compartmentalized cancer in different ways (e.g., healthcare team vs. cancer, self vs. negative thoughts). Given our findings, we recommend that the war metaphor should remain an integral part of cancer care, as not doing so could discount a framework that brings strength, continuity, and resilience to patients managing a cancer diagnosis, treatment, and recovery.

Although we argue that war metaphors should remain a part of cancer care, their potential negative impact on patient’s emotional wellbeing cannot be discounted. In this study, patients who did not use war metaphors nor find it helpful (n = 2) corroborated literature that criticizes the war metaphor for its deleterious psychosocial outcomes [25] and inaccurate logic of cancer especially when it is implicated in the tyranny of positive thinking (i.e., belief that failure to think positively during the cancer care experience could lead to poor clinical outcomes) [32]. Taken together, the positive and negative aspects of war metaphors can be discerned only within each patient’s context [8, 16, 43, 44]. In addition, although war metaphors are pervasive in cancer center advertising and public cancer discourse [2, 17, 18], our research demonstrated that there seems to be a multifocal origin for war metaphors. Friends, family, and religious communities have also referred to and introduced war narratives for many patients, thereby challenging the critique primarily directed at oncology clinicians for their use of war metaphors [12–15]. In addition, culture likely contributes to the origins, meaning, and implication for metaphors. Hence, ultimately, each patient and situation are unique, so we should personalize our approach to whether these metaphors are constructive or destructive for an individual context.

Clinical implications

Our findings raise a number of possibilities for future work. Metaphors manifest where stories meet—when patients and their communities make sense of a life lived with cancer [4]. Therefore, curiosity and humility are prerequisites for future research pertaining to the war metaphor. Clinicians can elicit metaphor use after getting to know a patient and their sources of resilience and coping, in their particular context (such as family and life-story, relationship with healthcare system, racial/cultural factors). There is not one metaphor that invariably leads to improved patient experience; rather, there needs to be room for negative and positive language in the uncertainty of illness, while acknowledging the empowering function of certain metaphor-based mindsets. Metaphor use must be fluid [8], leaving room for adaptation over the course of illness. Although helpful heuristics have emerged for clinical use of metaphor [4], there remains much work to be done to empower patients in this ordinary act of metaphor, of shared realities. Future studies should also expand on the relationship between coping and metaphor use within the patient–clinician interaction. Since selective use of metaphors may influence coping and clinical outcomes, particularly aggressiveness of care at end-of-life [45], future research should explore metaphor frameworks that improve communication and the overall patient experience, and their association with outcomes.

Study limitations

A few limitations are intrinsic to our study. First, although there was a balanced sampling of patients with different solid malignancies, this study population was still limited to demographics of one institution, the Duke Cancer Center, and all patients had health insurance. Since culture likely impacts the use and implications of metaphors, our patients’ experiences with metaphors may also not be generalizable to other cultures. Next, the semi-structured interview may have led to a biased sampling of those patients who use metaphors regularly. Although our small sample size and interview methodology (i.e., semi-structured interviews as opposed to ethnography or discourse analysis) was chosen to enable a deep, descriptive analysis that would result in clear clinical translation, the small sample size is not representative of all patient experiences of cancer.

Conclusion

Patients with cancer lean on various psychosocial mechanisms to cope with the uncertainty and difficulties that may accompany a cancer diagnosis, treatment, and recovery. Patients in this study shared that metaphorical language is one significant way that patients make sense of their diagnosis, and in cancer lay discourse, the war metaphor is prevalent. Although the war metaphor has been subjected to much critique in clinical settings, it could serve an important role in cancer care by promoting an approach-oriented outlook and improving communication. Patients must be met in their own context as metaphorical language is noticed because these are critical touchstones upon which clinicians can optimize communication and the patient experience overall. Metaphors have the potential to move us beyond the patient–clinician dichotomy into a shared reality of communal, equitable, and culturally conscious patient care. More research is needed to further explore how metaphorical language impacts the cancer care experience.

Supplementary Material

Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00520-022-07552-y.

Abbreviations

CEA

Carcinoembryonic antigen

GED

Tests of general educational development

Data Availability

Due to privacy and ethical concerns, neither the data nor the source of the data can be made available.