War metaphors in breast cancer – “brave” word angers some

The following is a guest blog post by Sally James, a Seattle-based freelance writer who is also one of our regular story and news release reviewers. She tweets as @jamesian.

bringyourbravelogo_500x161A recent campaign by the Centers for Disease Control is called Bring Your Brave and aims to get younger women between 18 and 44 to pay attention to their risks for breast cancer.

But some in the breast cancer advocacy community are calling foul on the campaign’s use of language, which they say is uncomfortably reminiscent of the “war” metaphor that has long pervaded cancer discussions. Several wrote to us via email to express their objections to the “brave” messaging.

“As a woman who was diagnosed with breast cancer at a relatively young age and is deemed a ‘survivor,’ I can affirm that there was nothing heroic or brave about my facing breast cancer,” wrote advocate Beth Gainer, who is on Twitter as @bethlgainer.

Gainer and others suggested that the CDC’s framing would exclude many women for whom the “brave” message, and its strong links to soldiering, simply does not resonate. Gainer further questioned the factual information provided by the extensive video and texts at the site, particularly the emphasis on living “a breast-healthy lifestyle.”

Does this mean “that women who are diagnosed with breast cancer did not live a healthy lifestyle?” she wondered.

We contacted the CDC and received a written response to some of the criticism from Temeika Fairley, PhD, who is an epidemiologist in the Division of Cancer Prevention and Control, and a health scientist helping to lead efforts at prevention.

“We acknowledge the many challenges that women and their families face with a breast cancer diagnosis. … So, it takes a measure of bravery for women with a family history of breast cancer to talk with their doctor about risk and whether genetic counseling and testing is appropriate because of the implications of a potential diagnosis. We understand that not every woman will identify with this language or relate to these feelings. However, many women identified with having to be brave about taking that first step with their doctor. That’s why we chose to frame our campaign in this way.”

There is a long history of patients complaining about the language of the “war” on cancer, for many reasons. They think it’s inappropriate to suggest that someone who’s died from cancer has somehow “lost” a battle — one that maybe they could have “won” had they fought harder. And they worry that violent language may encourage some cancer patients to choose overly aggressive treatments that offer little benefit and can cause debilitating side effects.

There is even research demonstrating that such metaphors may thwart prevention efforts. A University of Michigan study showed patients were less likely to take preventive efforts if “war” was the guiding metaphor. A news release on that study said: “Exposure to metaphoric language relating cancer to an enemy significantly lessens the extent to which people consider cancer-prevention behaviors.”

Patient-advocate Lori Marx-Rubiner, who is on Twitter as @regrounding, wrote, “There’s quite a debate about the continued use of war metaphors by, for and about cancer patients.” She believes each patient can choose their own language, but objects to society using war labeling. While presumably well-intended, the war metaphor prevents a healing atmosphere that allows patients to accept their own range of emotions, Marx-Rubiner wrote. She longs for a time when fear is accepted as a natural response.

“Rather than expect fear to be shoved down or pushed aside, it’s long past time that the reality of fear be given its due respect – patients, ‘previvors,’ and others need space to recognize and confront the myriad of emotions that come when facing disease. Bravery may come, but if we truly want to support women and men facing breast cancer, it, like any other emotion, must be an authentic of the individual, and not one that we are pressured into feeling. Isn’t it time?”

Another critic of the metaphor is Annette Bar-Cohen, MPH, who directs advocacy training programs at the National Breast Cancer Coalition, and who has been involved in public health for many years. She commented that the slogan didn’t make sense to her, and she also felt the campaign did not prominently display the fact that what are known as BRCA mutations are present in only 5-10 percent of all breast cancers.

Alicia Staley is one of the founders of the social media phenomenon known as #BCSM, or breast cancer social media. The group holds weekly live chats on Twitter where thousands of patients and others discuss and debate issues around the disease. Staley is disappointed on several levels. She is @stales on Twitter.

“This is another example of using the war imagery to promote awareness. What happens when you don’t feel brave? Why the hyper-focus on BRCA/previvor issues when metastatic continually gets swept under the rug?  … I think it falls way short of what the CDC could and should be doing.”

Addendum 2 hours after this was first published:

Three people, including Dr. Otis Brawley of the American Cancer Society, recently co-authored a Viewpoints article in the journal JAMA Oncology entitled, ” Advancing a Quality-of-Life Agenda in Cancer Advocacy:  Beyond the War Metaphor.

Editor’s note: The National Cancer Institute hosted a Twitter chat on July 22 about the psychosocial aspects of cancer. Click here to see a transcript of the discussion, which used the hashtag #copingcancer.

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Comments (9)

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Patti Bauer

July 21, 2015 at 12:40 pm

My 17 yr old child had cancer and ultimately we lost her to that terrible disease, I am offended by words like BRAVE and WAR. NO ONE fought harder to live than my daughter or our family to save her. We are offended by the connotation of the words ie: we didn’t fight hard enough. We didn’t move heaven and earth. We weren’t active in her treatment. We didn’t fight for one of the coolest people I will EVER have the honour of knowing and calling my baby….

    Sally James

    July 21, 2015 at 2:15 pm

    I am sorry Patti. I hope you will consider sharing your thoughts on Twitter tomorrow when the Nat’l Cancer Institute invites the community to talk about emotions. (1 p.m. ET #copingcancer)

    Catherine M

    July 21, 2015 at 9:10 pm

    Patti, I m so sorry for your loss. Please know that NOBODY blames a child for not making enough effort to beat cancer. I’ve never heard of anybody blaming the family for a child’s succumbing to cancer either. It just doesn’t happen. I know from personal experience that people will practically say to your face that you are to blame if you get cancer – because you didn’t make the right lifestyle choices. But nobody thinks a child is to blame if they do not survive cancer. Please have peace that you and your child did all you could to overcome cancer and that whatever words someone else uses to describe their cancer experience, it does not denigrate you or your child in any way. Think about it, no one blames a fallen soldier for not doing enough to save themselves in battle, why would anyone blame a child who had cancer for not living through it. It just isn’t something you should have to worry about. I am so sorry that this idea has even come into your world.

Catherine M

July 21, 2015 at 7:44 pm

When I faced breast cancer, it was a battle. I had to fight almost every doctor I encountered to get the treatment that saved my life. I fought the mammogram mill that misdiagnosed me. I fought the HMO that repeatedly provided second rate, and even negligent, care. I battled with more than one insurance company and provider to get my bills paid. I fought the fear and the pain and the TORTURE that passed for treatment. I fought for my life and my sanity while being slashed, burned, and poisoned within an inch of my life. I endured conditions and treatment that would NEVER be permitted on any battlefield! So in that sense it was worse than war. I laugh at waterboarding!

AND I WAS BRAVE because I have an extensive medical history from infancy that made every single procedure I underwent especially traumatic for me.

Nobody’s attempt at some PC bullshit censorship can take that away from me. One breast cancer “support group” engaged in this same censorship. They essentially kicked me out because, for me, cancer absolutely was a fight for my life and I was not about to go quietly. I went into it as a warrior and I came out of it one of the walking wounded. But I survived. And just like in any military battle, I had to watch many who did not. That was the hardest part. We are ALL heroes – the living and the dead. Nobody denigrates those who die in battle. The idea that those who loose their fight against breast cancer are perceived as somehow less worthy than those who survive is a made-up thing. It doesn’t exist. Nobody thinks those who die in battle are less than those who survive. So there is no need to make up a defense against it by censoring breast cancer survivors. It’s an absurd idea that needs to be dismissed as the drivel it is.

But America doesn’t want to see what we went through and the censorship of the terminology used to describe a person’s cancer experience is just the latest attempt to keep what is happening to women who must face breast cancer out of the public consciousness. This whitewashing of how the cancer experience is described is FAR WORSE THAN PINKWASHING!

We have not made much progress in breast cancer treatment methods in over 100 years. There has been NO DECLINE in the number of annual deaths in the last 50 years. As long as the public can be kept in the dark about what really happens to women who get breast cancer, little will change. I see this as an insidious attempt by Big Pharma, The Medical Industrial Complex, Big Chemical, Big Oil – all the entities that contribute to the cancer epidemic to try and keep a lid on women who want to describe how horrible this disease. If we allow this censorship of women who speak out in order to gain public awareness of their ordeal, gone will be any impetus to eradicate the disease and women will have to continue to battle, one woman at a time, against breast cancer instead of gaining public support.

Does anyone really think the AIDS epidemic would have been curtailed so quickly if activist groups had used namby-pamby terminology to describe what it was like to have AIDS? Would any progress be made against muscular dystrophy if Jerry never showed any sick kids? Those fighting breast cancer have spent too long trying to look good and feel better so that nobody has to be disturbed by what we are going through. It’s time for that to end. It’s time to be in America’s face about what breast cancer means – even to those who survive it. So now we have to use our energies and resources not only to work for prevention OF THE DISEASE, but to prevent those of us who’ve fought the disease from being silenced when describing what we went through.


    July 22, 2015 at 7:49 am

    Catherine, I applaud you for stating our situation in such a profound manner! Thank you.

    Lori Marx-Rubiner

    July 26, 2015 at 10:26 am

    Catherine, my goal was to respond to your comments but I’m not sure my phone will allow that, so I hope you see this.

    I’m sorry to hear how desperately you had to fight every step of the way through your cancer treatment – it is unacceptable and shameful! I’m sorry, too, that you landed in a support group that was unable to provide you support. Your experience should only ever be shared your way – and no one gets to judge that. Ever.

    However, I also think that those of use who are weary of the war metaphors should not have them forced upon us everywhere we turn. As someone living with MBC, I’m exhausted from the “battles” of breast cancer, and the idea of waking up, each and every day, to fight yet another one actually depresses me. As I go through line after line after line of therapy, I need to surround myself with peace, not war; with loving support rather than the pressure to do battle. And some days I need to not feel brave or strong, to not be a warrior.

    I believe when those around me have no words to support me other than war metaphors, we’ve limited the experience. The number of dear friends who repeatedly tell me I will fight this, I can win my battle, I’m strong enough to beat this… Odds are 99:1 I’m not going to win this. So am I weak? Will I have given up? Not hardly! Nor will, unlike in war, be the fault of the army defeated.

    I don’t think the point of the article was to water anything down or to bow to prevailing political correctness. I think it was to raise some awareness about the fact that some of use find the war metaphors damaging to our efforts in healing, and that we too should have a voice in how America’s conversation on cancer is framed. To be sure, I would never want to take from you the lens through which you experience cancer – it’s just not the right one for me.

    Wishing you abundant health!

Amy Byer Shainman

July 22, 2015 at 10:32 am

Hi Sally,
This is a taken from the CDC website and shares the focus of the CDC campaign. I am posting it here for your readers.
Bring Your Brave Campaign
The campaign’s target audience is women ages 18 to 44, particularly those whose family history and backgrounds predispose them to a higher risk for breast cancer at a young age. This includes women with a family history of breast or ovarian cancer and Ashkenazi Jewish women. Additionally, the campaign encourages women of average risk to live a breast healthy lifestyle.
Bring Your Brave Campaign Objectives
Encourage young women to learn their family history of breast and ovarian cancer.
Educate young women on the risk factors for breast cancer before the age of 45.
Inspire young women to talk to their health care provider if they think they may be at a higher risk for breast cancer.
Encourage young women to live a healthy lifestyle and be aware of their own breast health.
What is clear to me is that the CDC has very good intentions with this campaign. As a passionate Hereditary Cancer/ BRCA Health advocate and BRCA positive previvor (of Ashkenazi Jewish descent), I most definitely appreciate their efforts and focus.
When the campaign came out, I did let out a big sigh followed by an “Oh, boy”; marketing wise, I didn’t like the campaign name at all. I wondered–did the CDC consult with a marketing firm on the campaign? If they did, the marketing firm they used clearly had no “awareness” about the dislike of “war” metaphors amongst cancer survivors and previvors. I then wondered–did the CDC consult with a marketing company at all? Was this campaign name an “in house” decision? The only thing that was clear to me was that cancer survivors and previvors did not participate in any type of focus group about the campaign name nor were any breast cancer/hereditary cancer advocates consulted. If they had been, the campaign would surely have a different name.
“Educate” and “Inspire” are great key words from the CDC list of campaign objectives. Why wasn’t the campaign simply called “Educate & Inspire YOU”? Perhaps it wasn’t original enough? Perhaps all the other campaign name suggestions that were in the name pot didn’t roll so easy off the tongue?
Nevertheless, I summed the CDC campaign up to really bad name by really good, well intentioned people. I was thrilled that a government agency was focusing on BRCA. I viewed this campaign as a baby-step to the bigger picture of global hereditary cancer education. Ultimately, I decided that the CDC campaign with the bad name was still another opportunity to save lives–and for me, saving lives trumps all.
Amy Byer Shainman
The BRCA Responder @BRCAresponder
Hereditary Cancer/BRCA Health Advocate
BRCA1 positive previvor


    July 22, 2015 at 10:44 am

    Dear Amy and Catherine,
    You both bring important ideas to the table. I’m glad you are helping readers see additional frames for this discussion.

Chris Tachibana

July 28, 2015 at 12:35 am

Thank you, Sally and commenters. I support the suggestion to focus on education and inspiration while acknowledging the need to be activists. I work for Group Health Research Institute and we recently posted a commentary from one of our project managers that links to two articles relevant to this discussion. One is a powerful essay from journalist Laurie Becklund and the other is a summary of a Lancet study on providing women with information about the complexities of screening: https://www.grouphealthresearch.org/news-and-events/blog/2015/06/applying-computer-power-cancer-research/