War metaphors in oncology are controversial, to say the least. For some patients with cancer, the idea that they are “cancer warriors” in a “battle” with their disease is inspiring. Using such language gives them a sense of agency in a situation where very little is in their control. Many others loathe such language and are happy to tell you so. They see little value in thinking of their experience with cancer as a “fight.”

Oncologists are also split on this use of language. Many advise their patients to not use the metaphors, fearing that they are giving themselves too much agency, which is bound to lead to disappointment and guilt, should their disease take a turn for the worse. Still others, mirroring the behavior of patients, use the language of war, seemingly for the same sense of empowerment. 

As a patient with cancer, and a researcher of medical writing, I have seen many statements for and against this language, by patients and oncologists. But my research shows that its use by oncologists may be changing. 

Oncologists use of war metaphors in personal narratives 

My most recent research has looked at the ways oncologists use metaphors in their personal narratives: the published stories they tell about their patients, their careers, and their own families’ encounters with cancer. I first examined 435 personal narratives totaling 517,009 words, written by oncologists between 2010 and 2019, published in medical journals such as JAMA Oncology and the Journal of Clinical Oncology, as well as online sites such as KevinMD. War metaphors were fairly common in this sample, occurring about 0.87 times every 1000 words. By way of comparison, a study by Elena Semino and colleagues found that patients with cancer used war metaphors more than twice as frequently – 1.8 times per 1000 words. (That comparison is not exact for several reasons, but it does give a relative sense of how often oncologists use such language.)

I then extended the research, looking at oncologists’ narratives from those same sources, but from 2020 through 2022. The difference was startling. In the later sample, comprised of 125 narratives totaling 192,883 words, there were very few war metaphors – a mere 41 in total, or 0.21 in every 1000 words. What could account for such a change in the use of language?

The effects of COVID-19

The dates of the later sample make it clear: these narratives were written in what we could call the “COVID-19 era.” The content of the narratives confirms this, as COVID is a frequent topic of the narratives, especially in 2020 and 2021. And even when it isn’t the principle subject matter of the narratives, COVID hangs over the stories, with exhaustion and burnout as common topics.

I wondered if other metaphors had replaced the fairly common metaphors of war in the narratives, particularly “journey” metaphors. Researchers often link these two metaphor types, sometimes seeing journey as a possible replacement for war metaphors. In my earlier (2010-2019) sample, journey metaphors occurred 1.08 times per 1000 words. (Again, by way of comparison, Semino, et al. found that patients used them about 1.46 times per 1000 words.)

However, much as with war metaphors, in my COVID era sample, journey metaphors were used far less frequently: 0.25 times per 1000 words.

The next logical question to ask was, have the war and journey metaphors been replaced by other figurative language? The answer is No. There is, overall, a lack of figurative language in the later sample. Take, for example, the word “mask.” In the earlier sample, the word “mask” was typically used as a metaphor: a patient or an oncologist “masked” their emotions in a difficult situation. In the COVID era sample, there were more total uses of the word “mask,” but they were all literal, such as describing the scarcity of masks and other PPE.

New ways of thinking about language 

So why is there such a drastic change in the way oncologists use language in these narratives?

COVID-19 almost certainly played a role. As stated above, war metaphors have been popular with both patients and oncologists because they provide a sense of agency. The experience of having cancer is often a helpless one, and any attempt to exert some kind of control over the situation can be empowering. “Fighting” cancer provides that feeling of agency. Arguably, the journey metaphor operates in the same way. Taking a journey is a deliberate act. Like calling oneself a “warrior,” it, too, can be linguistically empowering. 

But there is frequently a lack of agency in the COVID era narratives. So many of them describe feelings of helplessness. There is no action, and no language, that can overcome those feelings. Only the literal description of what has been seen and experienced seems appropriate.

Interestingly, there is precedent for this. After witnessing the horrors of the Civil War, writers rejected what was called Sentimentalism in literature. The era of Literary Realism was ushered in, with a focus on the every-day, and “flowery” language was stripped bare and replaced by a sometimes journalistic attempt at objectivity through words. Something similar seems to have happened as oncologists told their stories in the COVID era.

The question remains, will this change remain in the way oncologists use language? Will war and journey metaphors be replaced by something else (there are lots of other metaphors to choose from to describe cancer and our experiences with cancer)? Or will we see less metaphor use of any kind by oncologists, and perhaps consequently by patients? 

All of this comes at a time when oncologists are being urged to pay closer attention to the language that they use, as evidenced by statements from ASCO and NCCN. 

At the same time, we shouldn’t discount the value of metaphor. Poetry can be helpful sometimes, and new language is sometimes necessary to describe a changing world. We may be experiencing a time of resetting, of reconsidering all of the ways that language shapes and reflects our realities, for patients and for doctors. And that could be a very good thing.

Robert McEachern is a professor of English.