The Oxford philosopher of language J L Austin died on 8 February 1960, just months after receiving a ‘grave’ diagnosis. His friend Isaiah Berlin called it a ‘dead secret’ – Austin himself had ‘no idea’ how little time was left. As Hilary term approached, Austin requested a mere four weeks’ leave until his glands ‘cleared up’. He died five weeks later.
Today, Austin is best known for speech act theory, which teaches that language does not simply convey information but performs actions. In short, we do things with words. One word, however, is conspicuously absent from Austin’s late correspondence. Cancer. Lung cancer, Austin’s ‘grave’ diagnosis, claimed his life at age 48.
Like many at the time, Austin’s doctors, family and friends avoided naming his disease. ‘Cancer’ was a whispered word, a taboo too terrible to speak. Physicians routinely withheld the diagnosis, fearing that merely uttering it would extinguish all hope and hasten death. As one writer observed:
Cancer patients are lied to, not just because the disease is (or is thought to be) a death sentence, but because it is felt to be obscene – in the original meaning of that word: ill-omened, abominable, repugnant to the senses.
That writer – Susan Sontag – like Austin, was an astute observer of the power of language. In Illness as Metaphor (1978), Sontag exposed how metaphors surrounding illness, especially cancer, do more than describe; they shape perception, reinforce stigma, and impose narratives that can harm. She called for a ‘liberation’ from these metaphors, arguing that we must stop treating cancer as ‘an evil, invincible predator’.
Sontag died of cancer in 2004. By then, the narrative had shifted. When she was first diagnosed with breast cancer in 1975, there were no pink ribbons or ads urging early detection and treatment. By her death, however, cancer had moved from private affliction to public crusade. Women marched in solidarity; men grew moustaches for Movember; athletes donned pink jerseys, while coloured wristbands signalled support for everything from leukaemia to pancreatic cancer.
Cancer was no longer a shameful obscenity but a rallying cry. Shattering the silence was undoubtedly progress. But with this shift came new metaphors – and new expectations. No longer an unspeakable fate, cancer became a battle to be fought, with patients cast as warriors, urged to ‘Fight Like Hell’. Drive through any major city in the United States, and you’ll pass billboards with slogans: ‘We Fight for You’; ‘Your Battle Begins Here.’ Cancer centres recruit patients, urging them to enlist. Public health campaigns preach constant vigilance against a lurking enemy needing to be stamped out before it takes root. What was once too fearsome to name became a call to action.
Many now worry the pendulum has swung too far. Overtreatment – intervening where it’s unlikely to help and likely to harm – has become a major problem in modern oncology. Take prostate cancer. In the US alone, more than 50,000 men are diagnosed each year with a low-risk instance of the disease. These cancers rarely spread, and observation is a safe approach, with outcomes equivalent to surgery or radiation. Yet more than half of patients still undergo aggressive treatment, risking incontinence, impotence and other harms – without clear benefit.
We treat not because it helps – but because the alternative feels like giving up
Similar patterns play out in other cancers. More than 50,000 women in the US are diagnosed annually with ductal carcinoma in situ (DCIS), a non-invasive form of breast cancer with a low risk of progression. Yet nearly all undergo surgery, with a third receiving mastectomies. Trials have shown that observation can be a safe alternative, but they struggled to recruit patients – and, even when they did, many crossed over to surgery. As one commentator noted, clinicians are conditioned to act, and patients have been ‘brought up to expect “cancer” to be removed.’
But overtreatment doesn’t stop at early stage disease. In the US, it’s estimated that nearly 700,000 people are living with advanced cancer. For many, the final stretch of life will be marked by intervention. One in three will receive aggressive treatment in their last months, and one in five will get chemotherapy in their final weeks. These treatments rarely prolong life and almost always diminish its quality, bringing exhaustion, nausea, hospital stays and lost time with loved ones. Despite guidelines discouraging such practices, the default remains action. We treat not because it helps – but because the alternative feels like giving up.
As a physician, I see this firsthand. Patients hear the word ‘cancer’ and brace for battle. Some tell me they’ll accept anything – however toxic – if it means getting rid of the disease. Even when the evidence supports watching and waiting, the very idea can feel like surrender. And even when the evidence supports palliative care, many still choose to ‘fight to the bitter end’. To quote one patient: ‘Doing nothing is no choice.’ Clinicians, too, feel pressure to intervene. The urgency doesn’t come from disease biology – it comes from the weight of words.
That’s why some oncologists now argue that we should drop the ‘dreaded C-word’: removing the cancer label from low-risk cases like early breast and prostate cancers could spare patients unnecessary treatment. We’ve come full circle – but for the opposite reason. What Austin’s doctors withheld to preserve hope, today’s oncologists would withhold to prevent us from doing too much. It’s a tempting solution to a serious problem. Cancer overtreatment harms millions and drains billions from healthcare systems every year. But is renaming really the answer?
To begin to unpack this, we can turn to Austin and his theory of speech acts. Imagine you’re diagnosed with a disease. It started with a yellowing toenail. Your doctor examines you, then says: ‘You have Disease X.’ It’s slow growing, she explains, though it may spread. There’s a treatment, but it has side-effects. Some patients, she says, choose to live with Disease X. You consider your options, opt for treatment, and are cured. You never think of Disease X again.
Now imagine a different diagnosis. This one began with a lump in your groin. Your doctor runs some tests, then breaks the news: ‘You have Disease Y.’ You shudder at the words. She tries to reassure you: it’s slow growing but can spread over time. The treatment has side-effects. But many patients, she adds, find it hard to live with Disease Y. She refers you to a support group, where you hear of patients who fought Disease Y and won. You choose treatment and achieve remission. You remain an active member of the Disease Y community. You see yourself as a Disease Y survivor.
What’s the difference between Disease X and Y? Between onychomycosis, a fungal toenail infection, and an indolent lymphoma, a slow-growing cancer of the lymph nodes? Yes, they differ in prognosis. But perhaps the most striking difference lies elsewhere. It lies in what Austin calls illocutionary force.
Illocutionary force is what words do in the very act of saying them – they create commitments, reshape roles, and influence identities. Take ‘I promise’: those two words don’t just express an intention; they create an obligation. Or take ‘You are guilty.’ Uttered by a judge, those words don’t just assign blame – they make you a criminal.
The fighter effect is a powerful driver of overtreatment
Likewise, the words ‘You have cancer’ do more than simply state a medical fact. A cancer diagnosis, like a guilty verdict, carries special illocutionary force. It doesn’t just describe a condition; it imposes a new identity. In short, it makes you a cancer patient.
And not just a patient – a fighter. ‘Conquer Cancer.’ ‘Fight Like Hell.’ These slogans don’t just inspire; they instruct. They set expectations: show strength, not weakness; determination, not passivity; persistence, not surrender; action, not inaction. Cancer isn’t just a diagnosis – it’s a call to arms. We can give this special illocutionary force a name. Let’s call it the fighter effect.
The fighter effect is a powerful driver of overtreatment. It’s what leads men with low-risk prostate cancer to undergo unnecessary prostatectomies. It’s what drives women with indolent breast lesions to receive mastectomies they may not need. And it’s what pushes patients with advanced disease to trade precious time for ineffective treatments at the end of life. The word ‘cancer’ demands action. In the words of one patient: ‘Something has got to be done.’
Recognising cancer’s illocutionary force brings into focus two competing strategies for tackling overtreatment: renaming versus reframing. Proponents of renaming – those who argue that we should drop the ‘dreaded C-word’ and simply call early cancers something else – focus on blocking the immediate impact of cancer’s illocutionary force. By leaving the word unsaid, they aim to prevent the fighter effect from taking hold.
But it’s a bit like building dams to stop flooding. It may protect some areas, but it doesn’t address the source of rising waters. The social and cultural currents that drive overtreatment remain, ready to surge again. To truly tackle overtreatment, we need a different strategy. Instead of building local dams, we must quell the rising waters. Rather than renaming the diagnosis, we must reframe its force.
To reframe cancer’s illocutionary force means shifting the linguistic and social practices that give the word its power. It rejects the narrative that cancer demands a fight, aiming to disarm – rather than simply block – its illocutionary force. It creates space for treatment decisions to be guided by risks, benefits and patient preferences rather than by bellicose expectations.
Why reframe rather than simply rename? There are at least three compelling reasons. The first is that reframing targets the root cause of overtreatment. Studies suggest that renaming early cancers with terms like IDLE (‘indolent lesion of epithelial origin’) may lead fewer patients to choose unnecessary treatment. But this is like trying to solve vaccine hesitancy by simply replacing the word ‘vaccine’ with a catchy acronym – say, BIBBLES (‘biological immunity boosting with bonafide, longitudinally established safety’). Clearly, that just skirts the issue. Renaming may block overtreatment in one instance, but it leaves the underlying misperception intact: that every cancer, regardless of risk, must be treated aggressively.
What’s more, renaming doesn’t just leave the misperception intact but reinforces it. Avoiding the term ‘cancer’ only feeds the narrative – shared by Austin’s doctors and critiqued by Sontag – that it’s something too terrible to name. Just as calling Voldemort He-Who-Must-Not-Be-Named only intensifies his infamy, shying away from the C-word cements cancer’s power. Renaming some cancers, while reserving the word for cases where ‘fighting’ is deemed appropriate, ultimately reinforces the very expectations that efforts to tackle overtreatment ought to challenge.
Reframing seeks to transform the norms and expectations around the diagnosis
The second reason to prefer reframing is that it respects patient autonomy. Imagine you have an American friend, Amy, who hates zucchini. She’s not allergic or intolerant. She simply fears that eating zucchini will make her sick. Worried that Amy’s missing out on zucchini’s culinary delights, you prepare your finest ratatouille. Knowing she hates zucchini, you strategically tell her your ratatouille is made with ‘courgette’. (Schooled in American English, Amy is unfamiliar with zucchini’s British synonym.) She eats your ratatouille.
In this scenario, it’s plain that you’ve deceived Amy. You’ve prevented her from making an autonomous decision about whether to eat your ratatouille given her preferences. Even if you believe her fear is baseless, your deceit isn’t justified. A better friend would help Amy understand that zucchini won’t harm her so she can confidently enjoy the vegetable.
Reframing aims to do just that: it addresses the fear directly, helping Amy see zucchini for what it really is. Renaming, by contrast, would have Amy eat ‘courgette’. This might be appropriate if she were your four-year-old daughter but it’s not appropriate for your friend.
Critics argue that renaming early cancers is paternalistic, infringing on patients’ right to make autonomous decisions. Members of the public have echoed these concerns, worrying that renaming feels deceitful. Though paternalism rightly raises red flags in modern medicine, it can sometimes be justified. Proponents of renaming defend it as a way to spare patients the emotional burden of the C-word, nudging them towards better choices. Yet this approach is ultimately flawed. It concedes that the fighter effect is problematic but does nothing to address it. As a result, patients whose conditions remain labelled ‘cancer’ are still subject to its full force, pushing them towards overly aggressive interventions.
Reframing offers a better path. Instead of sidestepping the problem, it seeks to transform the norms and expectations that surround the diagnosis. In so doing, it respects autonomy across the board – empowering all patients to make informed, proportionate decisions about their treatment.
When patients discover that their so-called ‘lesion’ used to be called cancer, trust erodes
The third reason to choose reframing is that it’s more robust. By robust, I mean resilient to shifting tides of medical practice, testing regimes and human behaviour that can undermine efforts to curb overtreatment.
Consider cancer screening. Recently, attempts to restrict mammography to women over 50 to prevent overdiagnosis and overtreatment sparked widespread controversy, with conflicting guidelines, professional disputes and media uproar – what became dubbed ‘the mammography wars’. Even where restrictive screening guidelines are adopted, adherence is patchy, influenced by personal biases and patient pressures. Meanwhile, emerging technologies like blood-based cancer-detection tests introduce new avenues for overdiagnosis, further complicating efforts to address overtreatment.
Renaming might seem more robust: if we can’t stop doctors from finding early cancers that don’t require treatment, we could at least change what they’re called. Replacing ‘cancer’ with ‘lesion’ or ‘IDLE’ might sidestep the fighter effect and thereby reduce unnecessary interventions. But this strategy, too, is fragile. As any physician knows, and as I’ve seen time and again in my own practice, such euphemisms inevitably prompt the further question. To borrow a line from the 1960 movie Ocean’s Eleven: ‘Look, doc. Give it to me straight. Is this the big casino?’
Moreover, when patients discover that their so-called ‘lesion’ used to be called cancer, trust erodes. And, in that moment of discovery, the full illocutionary force of the C-word re-enters – often with a vengeance. When Amy Googles ‘courgette’, she won’t be pleased.
Reframing is a more robust solution. Instead of relying on fragile euphemisms, it directly challenges the fighter effect – the underlying social forces that drive overtreatment. Rather than waging battles over labels, it aims to change the way we think and talk about cancer altogether.
Changing the way we think and talk about cancer might seem like a lofty, even impossible goal. But as Austin scholars have pointed out, illocutionary forces are not immutable. They are shaped and sustained by social conventions. A promise carries weight because society enforces the expectation to keep one’s word. A guilty verdict gains significance through laws and institutions, and through how society views the crime. These are not set in stone. Change is possible.
The same is true of a cancer diagnosis. Shifting illocutionary force means changing the conventions that give it power – moving away from seeing every cancer as a battle to be won at all costs, and toward treating it like other diseases, where decisions carefully consider a patient’s preferences, along with the risks and benefits of different options. That shift requires action across many fronts. Doctors must reconsider how they present the diagnosis, replacing militarised metaphors with language that emphasises patient agency. Public health campaigns must move beyond combative imagery, crafting messages that inform and empower without resorting to fear to drive decisions. Cancer centres, research institutions and media outlets all have a role to play in dismantling norms that perpetuate the fighter effect.
Since Sontag, many have called for such changes. Austin’s insights lend new clarity to these calls, showing us why and how change should occur. Seeing the diagnosis of cancer as a speech act with powerful illocutionary force – capable of shaping norms, expectations, even identity – reveals that overtreatment can’t simply be contained by renaming specific cancers. Overtreatment isn’t just a medical issue, but a social and cultural one too. To change how we treat cancer, we must rethink the illocutionary force that surrounds the diagnosis.
Sontag herself saw this clearly. She even lived through an important shift in that force. The unspeakable, ‘grave’ diagnosis that killed Austin had, by the time it claimed Sontag, become nameable, visible – even public. That was progress. But it wasn’t the liberation she’d hoped for.
Too many patients are convinced that stopping treatment or choosing palliation means surrender
She’d incisively critiqued cancer’s earlier metaphors of silence and despair, yet wasn’t immune to its newer ones. As her son David Rieff recounts in his memoir Swimming in a Sea of Death (2008), following her diagnosis Sontag became a ‘militant propagandist for more rather than less treatment’, pursuing extraordinarily aggressive regimens – first for breast cancer, and later for the leukaemia that followed. Though ‘less is more’ captured her artistic sensibility, Rieff writes: ‘when it came to cancer treatments more was always better.’ By today’s standards, much of her treatment would be considered excessive – its toxicity likely contributing to the second cancer that ultimately claimed her life.
Even after her bone marrow transplant failed, Sontag refused to stop. She remained determined to ‘fight for her life to the very end’, rejecting any talk of palliation and pressing her doctors to continue. As her son movingly recalls, it was ‘the opposite of an easy death’ – a slow, painful end, ‘stripped of her dignity’ and ‘unreconciled to her own extinction’.
As a physician treating patients with blood cancers, I’ve seen how too many still face a similar fate, convinced that stopping treatment, choosing palliation – or even death itself – means surrender. As one patient with advanced cancer put it: ‘If I were to die, which I most likely will, then I’m a failure, I’m weak, I’m not a good fighter.’
The metaphors have changed – but their force endures. Though stigma has given way to slogans, true liberation means casting off these narratives altogether. It means reframing cancer’s illocutionary force so that it’s no longer a death sentence or a battle cry but a diagnosis – one that, like any other, demands deliberation, not action by default.
We should all be free to attach our own meanings to the experience of illness
This isn’t to deny that a cancer diagnosis can be devastating. The words ‘You have cancer’ often signal life-altering challenges ahead. Cancer remains a leading cause of death, claiming far too many lives – many younger than Sontag and even Austin, whose enduring contributions to literature and philosophy were tragically cut short by the disease. Early detection and effective treatment – sadly, unavailable to Austin and ultimately unsuccessful for Sontag – can and do saves lives.
Yet even with advances in therapy, most cancers remain difficult to cure, and treatments remain long and arduous. In the face of such hardships, some might see the fighter effect as a source of strength, helping them endure a difficult treatment cycle or pursue early intervention. Some patients may choose to embrace the identity of ‘fighter’; others of ‘traveller’; others of something entirely different. We should all be free to attach our own meanings to the experience of illness.
To argue for reframing cancer’s illocutionary force is not to deny the gravity of the disease, the benefits of early treatment, or the hardships faced by patients. It’s to question whether the expectation to ‘fight’ should be baked into the very act of diagnosing cancer. Patients already grapple with complex decisions – navigating treatment options, weighing side-effects, and considering what it all means. They should not be further burdened by pressures to ‘fight’ because of the force of words. Decoupling the fighter effect from the cancer diagnosis allows patients to make their own informed choices – choices that weigh risks and benefits, not words. Only by shifting these norms can we achieve the kind of liberation that Sontag envisioned – it’s the only way to truly ‘de-mythicise’ cancer so that patients are free to shape their own identities and experiences.
As Austin reminds us, we do things with words. Words have the power to create norms, establish expectations, and shape identities. This power is rooted in linguistic and social conventions – conventions that, as Austin and Sontag well knew, are never fixed. In Austin’s day, cancer was an unspeakable diagnosis; in Sontag’s, it became a battle cry. Both were shaped by the language of their time. And both, in different ways, suffered under its weight.
Today, we stand at a different moment. Patients with cancer needn’t suffer in silence – but neither should they be summoned to war. If we are to carry forward Austin’s insights and realise Sontag’s vision, we must change not just the volume but the force of the word ‘cancer’. It shouldn’t be whispered. Nor shouted. It should be spoken clearly and calmly – so that patients can face a cancer diagnosis with autonomy, unburdened by expectation. To truly tackle overtreatment, we shouldn’t avoid the word ‘cancer’. We should transform what it means.
