Surveys of breast cancer patients show that more than 40 percent believe their disease was caused, at least in part, by "stress."¹ Many women seem to develop private scenarios linking the timing of their initial diagnoses or recurrences to particularly trying life events. But while all sorts of fanciful theories abound, and have since recorded history began, it's important to remember that despite decades of research, no one has yet proven that traumatic events cause cancer or worsen prognosis, or that certain kinds of people are more cancer prone. This is not to say that there is no mind-body interaction, but only that it is likely far more complex than we yet understand--and that emotional harm can result from simplistic theories of causality, thoughtlessly applied.

As Susan Sontag has observed, "Any disease whose causality is murky, and for which treatment is ineffectual, tends to be awash in significance."² Sontag might have taken this observation a step further to add that in the absence of certain knowledge about a mortal illness, theories of treatment and causality also run rampant. Whether or not you feel drawn to develop your own ideas about causality, at some point, you will probably encounter someone eager to offer up his or her own theory of why you got sick.

Many cancer patients find this infuriating, feeling that they are being blamed, somehow. It may help protect you from the meddlesome impact of the know-it-alls of the world if you stop to consider that it's probably their own fears and their need to preserve protective illusions about life that underlie such judgments and overconfident beliefs. Keep that in mind when the next well-meaning relative or friend offers a panacea, or refers to the "stress" or "loss" that brought on the cancer. Clearly, these people need, for whatever reason, to feel that life is orderly and fair, that every disease has its clear causes and cures. Wouldn't we all like to believe that everyone, at least potentially, could have complete control over catastrophic events? Wouldn't it be great to know that people would be safe from cancer if only their lives were exemplary?

Current social metaphors tend to imply that cancer patients are weak or ineffectual people who have in some way participated in their disease--the so-called "Type C" personality, defined as passive, emotionally inexpressive, conforming and unassertive. "The cancer personality is regarded...with condescension, as one of life's losers," Sontag observes. It's hard for anyone in today's pop-psych, self-help American culture not to feel at least some sense of self-blame or shame over having a life-threatening illness.

Unfortunately, in reaction to these pervasive beliefs and the pernicious victim-blame that so many find wounding, cancer patients sometimes take an opposite stance, and come to see their disease and their bodies mechanistically, to see the disease process fatalistically, and look only to Western medicine for guidance and help. This may be nearly as problematic as the opposite extreme, because real avenues of help and hope that might be explored are then closed off.

It comes as no surprise to anyone with metastatic cancer that there's a stigma associated with the disease. Common metaphors of the disease can actually contribute to this. When cancer treatment fails or is particularly arduous, medicine's mechanical images of the body as fixable machine often yield to those of all-out war. Disease becomes the invading enemy to be fought against with the arsenal of medicine. There is much talk of heroic measures, last-ditch weapons, courageous battles. Warlike imagery plays a role in eliciting fear when cancer is conceived of as an invincible enemy, mindlessly mowing down victims in its path.

Patients themselves become objects of fear. Even those who have a non-contagious disease like cancer can evoke anxiety and nameless dread, and are often shunned rather than supported. Pediatrician and writer Perri Klass, commenting on the widespread impact of the military metaphor among medical personnel, says that patients themselves "become battlefields, lying there passively while the evil armies of pathology and the resplendent forces of modern medicine fight it out. The real problem arises because all too often the patient comes to personify the disease and, somehow, becomes the enemy."³

Passivity equates with feeling defeated, a victim of disease. The resulting feelings of despair and hopelessness, devastating in themselves, clearly reduce the quality of day-to-day living for all concerned, patient and family members alike.

It's important to be aware of these metaphors, for they can exert subtle influences on both how you think about your disease and how you choose your treatments. However broadly and unconsciously they are used, the value-laden metaphors of war may well not be appropriate for you. Must the definition of courage for a cancer patient always be to "fight with the weapons" of medicine? Does choosing a less-toxic treatment protocol, for instance, mean you aren't "prepared for an all-out battle?" Does choosing to discontinue treatment mean "surrender to the enemy?" Is this choice less heroic than any other? Most importantly, does someone whose illness has progressed feel a sense of shame at having been "defeated?"

Many people choose to adopt other imagery, preferring to see cancer as a journey, for example, or finding a different image that conveys other aspects of the disease experience. Jenilu Schoolman once wrote me that she had come to conceive of her body as a multi-family apartment building. Her cancer was like an unruly tenant who couldn't be evicted, but had to be kept in line and taught respect for the other inhabitants of the building.

Like many people I interviewed, Caren Buffum found meaning through keeping a journal about her experience, using this metaphor to describe the process:

I think there is a comfort in knowing that as I slip closer to the end of my life, it is not growing smaller like a candle being burned to the bottom. That in writing my story, even if the writing only selectively captures what my life has been about, it becomes less like that candle and more like a road--though traveled on, it continues to exist behind me.

We are adversaries in a cold war. Cold, because were it all-out war, I would be totally absorbed in the land of the sick, engaged continually in hard battle, my breath in gasps and the fear of being overcome ever present. We (my illness and I) know we are engaged, and yet at home it is business as usual--dinner on the table at 6:30, "Jeopardy" at 7. The dog is walked and there is a small victory when he "does it" outside and not on my beige carpet. My son is accepted at Temple U. (a breath of relief )--then a treatment--engage the enemy--fatigue, queasiness, feelings of insufficiency…. This visit to the trenches saps my energy. I climb out to be greeted by my Westie's eager puppy kisses.

Notes:

1. Taylor, SE, Lichtman, RR, and Wood, JV, "Attributions, beliefs about control and adjustment to breast cancer," Journal of Perspectives on Sociology and Psychology, 46: p. 489, 1984.

2. Sontag, Susan, Illness as Metaphor (New York: Vintage Books, 1977).

3. Klass, Perri, "Life without euphemisms," The New York Times, April 27, 1986, Section 7, p. 21.