Cancer experience and its narration: an accidental study

The Impact of a Narrative Medicine Life Story Pilot Program on Press Ganey™ Scores in an Outpatient Cancer Center

Oncology patients face challenges beyond those directly affecting their cancer management. Guided personal narrative programs have been shown to help patients with chronic conditions and life-framing events. Few such narrative programs have been reported for cancer patients or analyzed for their impact on patient experience. We established our Life Story Narrative Program, modeled on the United States Veterans Affairs' "My Life, My Story" for outpatient oncology patients in our hospital's cancer center. Press Ganey™ patient experience scores from program participants were compared retrospectively with scores from patients who were not participants. Over an eight-month period, we invited 30 cancer center outpatients to participate. Twenty-seven individuals accepted, and 18 had their stories edited, approved, and scanned into their electronic health record. Cohort matching yielded a control arm consisting of 255 responses from 48 surveys, while the intervention arm consisted of 68 responses from 12 surveys. 78.4% of responses from the control arm were rated 5 compared with 100% in the intervention arm. The mean Press Ganey™ score response in the control arm was 4.71 compared with 5.00 from the intervention arm. Wilcoxon U value was 10,540 with p < .001. An outpatient narrative medicine program for cancer patients to tell their life stories can easily be organized. Patients were willing to participate, enrollment was brisk, and the use of resources was limited. Although our sample size was small, participation in our Life Story Narrative Pilot Program resulted in a statistically significant improvement in Press Ganey™ scores.

'Staying cool, calm and positive': A dialogical narrative analysis of emotional reactions in narratives about operable lung cancer

BACKGROUND

Patients with lung cancer suffer from physical, psychosocial and particularly emotional challenges. Twenty-five percent of patients with lung cancer are offered surgery as a potential cure. Nevertheless, 40% of surgically treated patients will experience recurrence. Paradoxically, research shows a dominant narrative of operable lung cancer patients 'being lucky', which silences other narratives about suffering, worries and emotional challenges.

AIM

To explore narratives about operable lung cancer, particularly emotional reactions to illness and suffering in these narratives.

METHODS

A qualitative design was applied. Six women and four men diagnosed with operable lung cancer were included from one university hospital in Denmark and interviewed 1 month after surgery using active interviews. The interviews were subject to dialogical narrative analysis. The theoretical foundation is social constructivism, with socio-narratological inspiration.

FINDINGS

A typology of three emotional narratives emerged: 'staying cool', 'staying calm' and 'staying positive'. All three types of narrative are characterised by managing emotional reactions. Staying cool is characterised by not showing emotional reactions; staying calm narratives acknowledge emotional reactions, but that they need to be managed so that they do not burden relatives; and the last, staying positive, is characterised by managing emotional reactions in a positive direction. Together this typology of three emotional narratives revealed that operable lung cancer patients are under normative pressure from these socially preferred narratives of ideal emotional reactions to lung cancer.

CONCLUSION

A typology of three emotional narratives were identified and can be called 'feeling rules' that guide patients after lung cancer surgery to manage their emotions. Consequently, if patients do not live up to these three emotional narratives of staying cool, calm and positive, they may be socially isolated and restricted from access to support.

The ambivalence of radiotherapy: Re-framing effects and their temporalities in treatment for gynaecological cancer

Within the biomedical paradigm, treatment effects are typically split into primary and secondary effects with temporality playing a key role in this separation. Yet, this kind of ordering of effects with some effects understood as happening on the 'side', secondary and temporary, does not fit with how they are experienced by many patients who undergo treatment for cancer. Drawing on empirical data from a research project that gathered narratives of women's experiences of radiotherapy for gynaecological cancer, we observe radiotherapeutic effects that are experienced as ambivalent and temporally diverse and as overlapping demands that the women endure and manage. We propose Derrida's concept of pharmakon as a relevant and useful analytic for understanding radiotherapy treatment, thus bringing into focus the ambivalent effects of radiotherapy - it is both therapeutic and toxic. Pharmakon, we argue, offers a way of disrupting the logics that govern current practices of therapeutic radiotherapy, and provides a way to re-negotiate the ordering and temporal understandings and practices of therapeutic efficacy, outcome and accountability of radiotherapy treatment - away from a temporal fragmentation of treatment effects and patients' bodily experiences to a focus on how best to support the whole patient in living with the ambivalent, temporally diverse and overlapping effects and demands of treatment.

Cancer Prevention Sense Making and Metaphors in Young Women’s Invented Stories

Despite the proven effectiveness of cancer prevention, the literature highlights numerous obstacles to the adoption of screening, even at a young age. In cancer discourse, the metaphor of war is omnipresent and reflects an imperative demand to win the war against disease. From the psychodynamic perspective, the risk of cancer forecasts an emotionally critical experience for which it is important to study mental representations concerning illness and health care. Through the creation of an invented story that offers a framework for imagination, our aim is to understand what the relationship with preventive practices in oncology means for young women and how this relationship is revealed by their metaphors. A total of 58 young women voluntarily participated in the present research, answering a narrative prompt. The stories written by the participants were analyzed using qualitative methodology to identify construct, themes and metaphors. Our findings identify four constructs: the construction of a defense: youth as protection; the attribution of blame about cancer risk; learning from experience as a prevention activator; and from inaccessibility to access to preventive practices: the creation of engagement. The construction of an invented story allows us to promote a process of prefiguration on the bodily, affective and thought planes invested in preventive practice and brings out the use of metaphors to represent cancer risk and self-care. The results allow us to think about the construction of interventions to promote engagement processes in prevention from an early age.

The incurable metastatic breast cancer experience through metaphors: the fight and the unveiling

Purpose: War metaphors are omnipresent in public and medical discourse on cancer . If some studies suggest that cancer patients may view their experiences as afight, few studies focus on the metaphors that patients create from their subjective experiences. The aim was to better understand the experience of four women with incurabale metastatic breast cancer from the metaphors they used in personal cancer blogs.Methods: An interpretive phenomenological analysis (IPA) was used to analyze these women's experience and metaphors of cancer.Results: Two metaphors carried the meaning of metastatic breast cancer experience: the fight and the unveiling. The results show that the war metaphor had a unique meaning for the bloggers who lived with incurable breast cancer: they revealed the difficulty of fighting cancer and eventually collapsing in battle, although a renewed look at life had developed in parallel to their struggle. The bloggers thus tried to lift the veil on this complex experience.Conclusion: The results highlight the need for women with metastatic breast cancer to be able to tell and share their experience in a supportive context and to reinvest the war metaphor in order to express themselves in a more authentic way.

The social meanings of choice in living-with advanced breast cancer

Individual choice is valorised as a core social value; yet the necessity and desirability of making choices takes on new significance for people living with incurable cancer who are required to make often difficult decisions about treatment, care and family life, amidst considerable vulnerability and precariousness. There has been comparatively little exploration of how choice is negotiated and made meaningful under the spectre of incurability and a contracted future. In this paper, drawing on multiple qualitative interviews with 38 women with metastatic breast cancer, we explore how they experience and give meaning to choice in relation to their health (and beyond) in their daily lives. Our analysis highlights that while exercising choice was sometimes a concealed or silent pursuit, choice was always a socially negotiated and temporally unfolding process, nested within relational and interpersonal dynamics. Choices were also often constrained, even foreclosed, due to situational and relational dynamics. Yet even in the absence of choice, the idea of choice-as-control was discursively embraced by women. We argue that greater attention is needed to the affective, temporal and economic dimensions of choice, and how treatment decisions are asymmetrically structured when considered within the normative context of cancer.

Narrating the nadir: examining personal and vicarious stories of cancer-related low points among survivors and romantic partners

Objective: To investigate low point autobiographical narratives among cancer survivors and romantic partners.Design: Cancer survivors (Study 1) and romantic partners (Study 2) narrated the low points of their cancer experiences. Partners also narrated stories of cancer survivors' low points. Narratives were coded for their manifest content, as well as redemption (negative-to-positive arc), contamination (positive-to-negative arc), and tone (positive or negative valence).Main Outcome Measures: Self-reported measures of health and well-being (life satisfaction, cancer-related worry, impact of cancer).Results: The diagnosis moment was the most frequently recognised low point among survivors and partners. Survivors who narrated contaminated low points reported marginally less somatisation, salience of cancer recurrence, and that cancer had a marginally less positive impact, relative to survivors whose narratives did not contain contamination. Tone in partners' low points predicted marginally less worry and more somatisation. The tone of their vicarious low points negatively correlated with anxiety.Conclusion: This research contributes to the growing body of work examining, and giving voice to, the experiences of cancer survivors and those close to them. As such, it informs applied health researchers of potentially challenging cancer-related experiences, and the way(s) in which the storying of these experiences align with psychological flourishing.

The collective/affective practice of cancer survivorship

Whether within an atmosphere of hope, or amidst relations of fear, the emotions of cancer are unavoidably collectively produced. Yet persistent individualistic paradigms continue to obscure how the emotions of cancer operate relationally - between bodies, subjects, discourses, and practices - and are intertwined with circulating beliefs, cultural desires, and various forms of normativity. Drawing on interviews with 80 people living with cancer in Australia, this paper illustrates why recognition of the collective enterprise of survivorship - and the collective production of emotion, more generally - is important in light of persistent, culturally dominant conceptions of the individual patient as the primary 'afflicted', 'feeling', and 'treated' subject. Building on previous work on affective relations and moral framings, we posit that the collective affects of survivorship inflect what people living with cancer can, and should, feel. We highlight how such things as hope, resignation, optimism, and dread are 'products' of the collective affects of cancer, with implications for how survivorship is lived, felt, and done.

Feeling lucky: hierarchies of suffering and stories of endometrial cancer in a Danish context

Illness stories are a prime analytical way of understanding patient perspectives on cancer. Nevertheless, limited studies have focused on stories of endometrial cancer. An ethnographic study including participant observation and interviews among 18 Danish women with endometrial cancer was conducted to examine prevalent stories and the ways the women responded to them. In this article, the analysis focuses on two exemplary cases, which present a line of issues related to the kinds of experiences that suffering includes. Findings illustrate that feelings of luck were central to the experience of being diagnosed, treated and cured, which was related to the way health professionals framed endometrial cancer as favourable through notions of curable/incurable, trivial and gentle/invasive and brutal, and aggressive/non-aggressive. Drawing upon the concept of a 'hierarchy of suffering', we exemplify how women tended to scale own experiences of suffering against others', leading some to believe they were not in a legitimate position to draw attention to themselves nor seek help and support, despite adverse physical, psychosocial effects. Thus, feelings of being lucky were intertwined with a sense of ambivalence. We conclude by discussing how suffering arises within a moral context, suggesting that the ways we speak of cancer may make some experiences unspeakable. This calls for increased clinical attention to more diverse narratives of cancer.

Before narrative: episodic reading and representations of chronic pain

This article suggests that some illness experience may require a reading practice less concerned with narrative coherence or self-authorship, and more interested in the value of textual fragments, episodes and moments considered outside a narrative framework. Chronic pain can pose multiple challenges to the narrative orientations celebrated in both 'survivorship' discourse and classic medical humanities scholarship. In its recalcitrance to cure, its often mysterious aetiology and its complex blend of somatic, interpersonal and affective elements, representations of chronic pain can require a richer vocabulary of temporality. I draw on contemporary affect theory to augment the available critical vocabulary for the textual representation of protagonists' temporal orientation within illness experience, identifying a language for the emergent present that resists a narrative form. Beyond identifying narrative 'incoherence', affect discourse gives a way to recognise the strained, equivocal labour of incoherence, of inhabiting a cryptic present moment. Affect theory's attention to the emergent present may give a way to read incoherent 'chaos' outside from a narrative framework, not only as a dark, formless stage in a personal story. To expand our vocabulary for this position, I offer a term for a particular affective experience of the present amid repeated marginalisation: the temporality of thwarted connection. I illustrate how these concepts can enable an alternative reading stance by offering a brief analysis of Lous Heshusius's hybrid autobiography and academic study, Chronic Pain from the Inside Out.

Living Well? Strategies Used by Women Living With Metastatic Breast Cancer

Metastatic breast cancer is a disease of changing status-once an imminent death sentence, now a chronic (albeit incurable) disease. Medical intervention advances mean women with metastatic breast cancer now have symptoms alleviated and, potentially, life extended. Living with this disease, however, requires more than a medical approach to symptoms. We were interested to know whether women manage, and if so, how, to "live well" with metastatic cancer. We conducted interviews with 18 women. Women differed in the approaches they used. Most common was the attempt to reestablish a sense of normality in their lives. However, a second group reevaluated and reprioritized their lives; and a third group was restricted in their capacity to live well because of symptoms. The findings provide the foundation for future research exploring normalization of experiences of metastatic cancer, and other chronic illnesses, where people are living with knowledge that they have contracted time.

"Surviving is not the same as living": cancer and Sobrevivencia in Puerto Rico

"Cancer survivorship" is an evolving concept that has been elaborated to a large extent in the mainland U.S. through the work of national advocacy organizations, and it has served as a source of cohesion for many people who have experienced cancer. However, anthropologists and other social scientists have argued that dominant meanings of survivorship-such as the idea of "cancer as a gift" or the role of positive thinking in influencing the disease course-reflect distinctively American cultural values, and survivorship outside the U.S. has remained largely unexplored even while the concept has gained some traction globally. This paper explores how the concepts of "survivorship" and "survivor" are engaged in the setting of Puerto Rico, an unincorporated territory of the U.S., and how well they are seen to explain the nature of post-treatment life. Ethnographic fieldwork for this study was conducted over 12 months split between two field visits (2 months and 10 months) between June 2010 and March 2012 in San Juan, the capital city, and Ponce, a smaller city on the southern coast. This paper is based on interviews with 23 participants treated for cancer as young adults. Participants drew from many of the prevailing discourses of survivorship-such as transformation and the importance of optimism-as well as from what they understood to be distinctive aspects of Puerto Rican culture and identity, in the crafting of a local understanding of post-treatment life. Support organizations played a key role in shaping roles and expectations associated with having had cancer, and in solidifying particular views of survivorship more broadly.