A Proposal: Seven Steps to Eliminating the “War” Analogy in Cancer Care

A Proposal: Seven Steps to Eliminating the “War” Analogy in Cancer Care

Matthew S. Katz, MD

Mar 03, 2014

From a philosophical standpoint, one of the things I hate most about cancer is the use of “war” analogies. The “battle” may mobilize patients and families, but it may also interfere with education and informed decision making. And both patients and clinicians often take recurrence or disease progression personally as a failure. Even when everything is done perfectly, the outcomes aren’t. Why compound grief with the unnecessary stigma of “losing the war”?

Medical jargon also can interfere with retaining information effectively, and as a result, I have come up with plain-language descriptions as much as possible. I try to use informative, nonthreatening analogies in explaining cancer and treatment. In my limited experience, people seem more engaged, ask more questions, and seem to retain what I’ve explained better. Here’s an example.

Lymph nodes and lymphatics by analogy

The lymphatic system is often misunderstood. In the setting of explaining the disease, many patients have heard about them for the first time at a cancer diagnosis, usually with referring to the cancer spreading and being bad. The issue comes up not only at first diagnosis but also on post-treatment scans and follow-up visits.

The analogy in use for the lymphatic system is that it’s our body’s security alarm system. It runs throughout the outside (skin) and has wiring (lymphatic channels) that run with the arteries and veins all through the body, allowing your body to detect an infection or injury and mount a fever and the immune response. Lymph nodes are like detection stations for the system. Lymph nodes are positioned throughout the body, but they can be an easy path of least resistance for cancer cells to use to travel.

From my experience, this analogy resonates with people, is a reasonably good representation of the disease process, and lessens fear and anxiety by providing an understandable comparison. It also avoids the fear factor of terms like “invasion” that we often use.

If I’m only discussing lymphatics in the setting of discussing side effects like lymphedema, I will use a highway analogy: arteries and veins are like the interstate, and lymphatics are more like a parallel access road to help move fluid back and forth. If the lymphatics are eliminated, in some cases the interstate can’t handle the traffic and fluid backs up. Lymph node removal sets up the potential for this backup, or lymphedema, which may be brought out by certain stressors that increase traffic. So a goal to limit lymphedema is to avoid those activities or exposures that stress the system.

These are two analogies that have worked well for me. What if we shared all of our best analogies and ways of describing cancer in a healthier way?

A proposal

Here is my suggestion: Let’s create an online analogy bank as a resource for better communication. Here’s how we could do it:

1. Build a platform. We need a way to share the information, designed to allow us to classify the type of information, i.e., analogies for different scenarios. That might be accomplished with a simple contact form tied to a database. Tagging would also be used for multiple purposes.

2. Share your analogy/story. Do it in plain language, best usually at a 7th to 8th grade educational level. Simple without medical jargon seems to work best. Submitters should not be anonymous, in my opinion.

3. Search tool to find the right analogy, right context. The best dynamic search tools I’ve seen are SmartPatients.com’s clinical trials search engine and Elance.com’s search engine to find web developers or other freelancers. I’m sure there are others; bottom line—search should be easy to use.

4. Vote analogies up or down. These votes would be subjective, but they may help distinguish what works from what doesn’t. The best analogies may filter to the top for more general use. It would be cool to have separate voting for clinicians and patients/caregivers, but I have no clue how to do that.

5. No comment? I’m mixed on commenting. It can be great, but it’s a massive hassle for spam/trolling. At least at the start, I’d favor voting over comments.

6. Freeware it. If an analogy bank creates great content, share it. Rather than trying to make it proprietary, I’d favor using a Creative Commons license, which allows for noncommercial use/tweaks with attribution.

7. Remix it offline. For the stories that resonate best with patients, use it in the exam room. Make a pamphlet. Use it in an educational video or audiotape.

What analogies do you use that help make it easier to explain medical concepts to your patients? Please consider sharing them and your thoughts on this proposal for a database.

Let’s make sense, not war.


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Brian Richard Bird, MRCP

Mar, 05 2014 2:34 PM

 We need analogies for immunotherapies like ipilumumab. I try "taking the brakes off the immune system so it can attack your cancer".

Matthew S. Katz, MD

Mar, 05 2014 4:38 PM

I agree, we should have good analogies that work for each disease, and each treatment we use to help.  I'm just a rad onc so I only have a few drugs: photons, electrons, protons and a few other charged particles. I really only use the first two.

I would be interested in hearing from specialists who use this drug.  My inclination would be to describe ipilimumab as restoring normal immune function and its ability to recognize self (healthy cells) from melanoma cells so that the immune system can do its job. There should be some way to avoid "attack".  Any thoughts, readers?

David L. Graham, MD, FASCO

Mar, 06 2014 3:16 PM

This relates to a lesson I was taught early on in med school. The two parts of learning medicine are learning it for yourself and then unlearning it enought to explain it for others.

I'll freely admit that I can easily fall back on jargon if I'm less than comfortable with the concepts.

For rituximab (but expandable) I have used the image of planting a flag on the cells to help your body know they aren't supposed to be there.

Matthew S. Katz, MD

Mar, 08 2014 9:46 AM

Thanks for sharing, David.  It's very easy to use the jargon, we're trained in it like a new language and it makes sense to other medical professionals - usually.  Thanks for sharing your analogy for rituximab!

ASCO Admin

Apr, 29 2014 11:18 AM

This blog post on analogies was picked up by the national blog KevinMD. In the spirit of connecting the conversations, here is the link to the KevinMD site.

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