Linnea Duff learned at age 45 that she had developed lung cancer, she practically encouraged people to ask if she had ever smoked.
But in the eight years since, her feelings have soured considerably on the too-frequent question, and she’s developed an acute sense of solidarity with fellow patients: smokers, former smokers, and never-smokers alike.
“It’s just so inappropriate,” says Duff, who believes that people with other serious illnesses don’t field so many intrusive queries. “Would you ask someone, ‘Did you eat too much?’ or ‘Did you have too much sex?’ ”
Tobacco ranks at the top of the stigma list when it comes to behaviors that have been linked to cancer. It’s a list that continues to lengthen: excessive drinking, sun tanning, exposure to the sexually transmitted human papillomavirus.
Recently, frequent acid reflux has been blamed for a startling increase in the incidence of some esophageal cancers, raising the question of whether people could be criticized for indulging too much in fatty food, alcohol, or other heartburn triggers.
Cancer patients may be asked about other, even more tangential behaviors, such as their ability to handle stress, says Larry Lachman, a clinical psychologist in Monterey, Calif., who counsels people with chronic illnesses.
Lachman recalls speaking with an alternative medicine practitioner shortly after his own prostate cancer diagnosis in 1997. Lachman, then in training to become a psychologist, was exploring both traditional and alternative medicine approaches.
He assumed that physicians would be blaming and judgmental compared with holistic practitioners. The reverse proved to be true. Lachman spoke with a reflexologist following cancer surgery: “First thing she said to me was ‘Why did you have to bring cancer on yourself? Why did you have to manufacture your tumor?’ ”
As a longtime medical reporter, and someone whose own mother died of lung cancer years ago, I’ve seen all sides of the stigma issue. I first spoke with Duff for an article about drug research studies she’s participated in.
The New Hampshire mother of three has responded remarkably well to the treatment for her malignancy, now classified as stage 4. As I wrote the piece, I wrestled with whether to include the fact that she had never smoked. Did it matter? Was it relevant to the research-driven story she had to tell?
A few months ago, Michael Douglas inspired plenty of chatter when he appeared to indicate that his stage 4 throat cancer was linked to HPV and oral sex. (A spokesman for Douglas later said that the actor was merely discussing HPV as a potential cause.)
But it got me thinking all over again about stigma and our society’s fixation on blame, and whether insinuations that cancer patients are responsible for their disease will become more common as additional behavioral links are identified.
As a reporter, I believe in the power of health information to educate and hopefully, in some cases, to motivate people to change. I’ve written umpteen thousand words about sunscreen, smoking cessation, and other cancer prevention efforts.
Given our family history, I’m happy that school health classes have transformed my 10-year-old into a walking anti-tobacco poster. The Douglas buzz may have paid off from a public health perspective, inspiring some people to protect themselves or their children with the HPV vaccine. But to what degree do these sorts of educational efforts stigmatize, and thus erode compassion for, individuals once they do become ill?
Duff believes that the recent Douglas discussion illustrates the rather perverse—and for some of the patients involved, quite painful—hierarchy of the cancer blame game.
After all, the actor has a well-documented history of smoking and drinking. Duff says the potential HPV connection might actually boost his standing when it comes to stigma. “I think in our current culture that, even though there may have been some snickering behind the scenes, I don’t think that oral sex is going to be viewed as negatively as even cigarette smoking,” she says.
For every 1,000 men who are smoking at age 65, 89 of them—or nearly one out of 10—are expected to die of lung cancer within the next decade, according to a 2008 study in the Journal of the National Cancer Institute. (For nonsmoking men, the number is four in 1,000.)
That’s not the sort of Russian roulette I’d be eager to play; I’ve never smoked. But the data show that even years of lighting up don’t guarantee cancer—genetics and other environmental exposures are part of the cancer-causing stew, along with a hefty measure of chance.
Judgments about behavior not only unsettle and stigmatize the patient, but reflect the interrogator’s own insecurities. Frequently, those disease detectives are attempting to regain a sense of control amid the inherently random and sometimes unjust world that we all reside in, according to researchers who have studied stigma.
Psychologists refer to this as the “just-world hypothesis,” a bias in thinking and perception that was first described by psychologist Melvin Lerner and colleagues more than four decades ago, and which has since been documented in numerous books and articles.
“I think that in one part there is a fundamental assumption in our society that the world is a just place, and that bad things don’t happen to good people,” says Gerald Devins, a stigma researcher and senior scientist at the Ontario Cancer Institute in Toronto. “And I think when bad things happen to good people, it’s threatening to everybody.”
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