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The Nine Cancer Frames: A Tool to Facilitate Critical Reading of Cancer-Related Information

The Nine Cancer Frames: A Tool to Facilitate Critical Reading of Cancer-Related Information People’s ability to critically assess cancer-related information is essential from a preventional and therapeutic, as well as a general democratic perspective. Such cancer literacy is not just about acquiring factual knowledge. It also involves the abil- ity to analyze how the information is contextualized—how cancer is framed. Previous research concerning the framing of cancer in public discourse is voluminous and penetrating but also fragmented and inaccessible to non-experts. In this study, we have developed an integrated and applicable tool for analyzing cancer discourse by systematically classifying distinctive ways of framing of the concept of cancer. Building on previous research and an inductive framing analysis of a broad range of public cancer discourse, systematically selected from British and Norwegian newspapers, we have characterized nine cancer frames: the biomedical, the environmental, the epidemiological, the personal, the sociopolitical, the economic, the antagonistic, the alternative, and the symbolic frame. This framing scheme may be applied to analyze cancer-related discourse across a plurality of themes and contexts. We also show how different frames combine to produce more complex messages, thereby revealing underlying patterns, strategies, and conflicts in cancer communication. In conclusion, this analytical tool enables critical reading of cancer-related information and may be especially useful in educational initiatives to advance health communication and public understanding of cancer. Keywords Cancer communication · Framing analysis · Health literacy · Mass media · Social science · Medicine · UK · Norway Introduction At the individual level, the word cancer is laden with fear and stigma [3]. Cancer prevention, screening, and therapy Cancer literacy, meaning people’s ability to critically assess involve difficult questions related to ethics and equality [ 4, cancer-related information, is increasingly important. Over- 5], and people’s understanding of these issues has imme- all cancer incidence and prevalence are rising, primarily diate effects on health awareness, care-seeking behavior, because of an aging population [1]. The worldwide annual and engagement in screening programs [6, 7]. How patients cost of cancer is estimated to more than US$ 1 trillion. Can- understand cancer influences how they relate to the disease cer therapy is a booming industry, and cancer research is and potentially its course of development, their quality of a major driver of the ongoing biotechnological revolution life, and even survival [8, 9]. [2]. To assure democratic decision-making and develop- Overall, there is a strong need for tools and methods that ment, there is thus a strong need for the general population facilitate the development of cancer literacy. People should to understand cancer and its impact on society. be able to critically assess cancer-related information from difference sources, especially the wide range of content provided by the mass media. Besides formal education, the * Jarle Breivik media represent the public’s primary source of information jarle.breivik@medisin.uio.no regarding health and science [10, 11]. TV and online news Department of Behavioural Medicine, Institute of Basic channels convey the voices of patients, researchers, health- Medical Sciences, Faculty of Medicine, University of Oslo, care providers, and public institutions, and the media both Blindern, P.O.Box 1111, N-0317 Oslo, Norway shape and reflect public understanding of cancer. National Resource Centre for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway 1 3 Journal of Cancer Education (2022) 37:1918–1927 1919 Developing cancer literacy is not just a matter of acquir- aspects of cancer discourse. In this study, therefore, we have ing factual knowledge about the relevant issues. It also developed a unified framing scheme, which facilitates criti - involves the ability to analyze how the information is cal reading of cancer-related information across a wide range contextualized. To make sense of cancer—or any other of themes and context. issue—information has to be organized into an intellectual framework; it has to be framed [12, 13]. When people com- municate, they frame their stories by using certain words, facts, depictions, metaphors, sources of information, and Material and Methods images. Accordingly, a particular concept may be presented or described in ways that communicate different meanings. Drawing on the seminal work of Goffman [ 12], we regard frames as “schemata of interpretation” by which people A gene, for example, may be framed as a physical entity, a risk factor, or a symbol of relationship, depending on the make sense of issues and events. Further elaborated by Ent- man [22], these mental frames are embodied in the key- context and the purpose of the communication [14]. Each frame conveys a different interpretation of reality [ 15], and words, metaphors, concepts, symbols, and visual images represented in different items of communication. framing analysis is a powerful tool, in research as well as education, for exploring the underlying process of commu- Framing analysis is the process of identifying and explor- ing such frames and may be either a qualitative or quan- nication [16]. Many studies have investigated the framing of cancer- titative method. For this study, we applied a qualitative approach, looking to characterize how the concept of cancer related discourse. Some have focused on a single issue and identified narrow, issue-specific frames. Kolker [17], for is framed from a newly selected material. The process was primarily inductive, but it was also informed by the literature example, found that patient advocacy groups frame breast cancer as an epidemic, a problem of gender equality, or outlined above. To validate, refine, and supplement previ - ous research in the field, we set out to analyze a wide body a threat to families. Others have identified more generic frames, including conflict , human impact, and economic of public discourse concerning cancer, and we found that a broad selection of online newspaper articles represented consequences, or episodic versus thematic news frames. Andsager and Powers categorized breast cancer coverage a pertinent source of information. Including news reports, interviews, features, editorials, commentaries, book reviews, into a basic information, a research, and a personal stories frame [18], whereas Park and Reber added a social support/ and informational articles about health and science, this material conveyed many different societal voices and rep - educational frame and a social/economic/political frame to this scheme [19]. resented a comprehensive selection of cancer-related infor- mation. Moreover, online newspaper articles represented Other studies have identified frames based on how mass media discourse attributes responsibility for the causes and an easily definable material, readily available in searchable databases, also for scrutiny by other researchers. solutions of cancer [20]. Clarke and Everest divided cancer- related news into a lifestyle frame, which focuses on individ- To gain insight into the contemporary European context in two different languages, we chose to analyze leading daily ual responsibility and solutions; a political/economy frame, which emphasizes the corresponding societal aspects; and a newspapers from the UK and Norway in the period from 2013 to 2018. To increase representativeness of the study medical frame, which underscores biological explanations and biomedical solutions [21]. regarding the entire landscape of journalistic styles and the respective socioeconomic readerships, we included equal Another focus of research concerns the use of metaphors. Many studies have addressed the use of war metaphors and numbers of articles from an elite, a mid-market, and a tab- loid newspaper from each country. Respectively, we selected the depiction of cancer as an enemy [22]. Sontag also dem- onstrated how cancer often functions as a metaphor for both The Guardian (GU), the Daily Mail (DM), and The Sun (SU) from the UK, and Aftenposten (AF), Dagbladet (DB), and monstrosity and uncontrolled growth, whereas Sontag [3] and others have discussed a mystical, alternative, and New Verdens Gang (VG) from Norway, building on the previous classification by Carver et al. [ 24]. Age perspective to cancer. Finally, multiple studies have described how cancer is presented from a personal and psy- Cancer-related articles were retrieved from the electronic databases Factiva (UK) and Atekst (Norway) by searching chological perspective, tending to describe the experience as a journey, heroic struggle, or test of character [23]. for cancer and kreft, respectively. To achieve a sample, both random and balanced, over the entire time period, the In summary, the literature on the framing of cancer dis- course is rich and insightful but also quite fragmented and resulting lists of articles for each newspaper were sorted by date, and 100 articles per newspaper were selected at regular inaccessible to the general public. We find no study that combines the different frames, perspectives, and metaphors intervals. Irrelevant results referring to the cancer zodiac or passing mentions of the word cancer, for example, in the in an applicable educational tool for analyzing the contextual 1 3 1920 Journal of Cancer Education (2022) 37:1918–1927 name of an organization, were excluded and replaced by the and we here present the characteristics of each frame and subsequent article in the list. how it is differentiated from the other frames: Using previously described frames and metaphors as a starting point, we then conducted a systematic framing The Biomedical Frame An obvious and intuitive way of analysis of the 600 articles. The three coders (N.P., C.M., framing cancer is to present it as a disease: a biomedical J.B.) began analyzing identical sets of five articles, address - problem characterized by the uncontrolled growth and ing the question: what kind of problem or issue is cancer spread of cells within the body, similar to how cancer is according to this article? Recognizing that one article could presented in a textbook of pathology. This frame was also comprise several cancer frames, we highlighted which text prevalent in our material of newspaper articles. These arti- corresponded to which nascent frame, subsequently compar- cles focused on the physical and technical aspects of cancer ing and discussing coding until consensus. and cancer treatment: “Its growth is driven by cancerous After five such rounds of coding, a clear pattern started to stem cells that are resistant to chemotherapy and radiation” emerge, and for the rest of the material, we only discussed (DM008). “Researchers have found the MC1R gene vari- articles that the coders identified as ambiguous or incompat - ant increases the number of mutations in skin cancer cells, ible to our previous classifications. Aiming to develop an multiplying the risk” (SU030). applicable educational tool, we sought a pragmatic balance Such articles typically described cancer at the level of between a framing scheme sensitive to the nuances of cancer cells, organs, or the body system, often in terms of genetic discourse and one that was easy to explain and simple to use. mutations and biological mechanisms. They depicted cancer Throughout the process, we also compared the emerging as a biological phenomenon, a tumor or growth that might frames with trends and perspectives identified in previous spread, invade, or metastasize and could also present infor- research (presented above). mation about symptoms, diagnostics, and therapeutic prin- The study did not involve human subjects or sensitive ciples. The topic was often related to cancer research, and information and required no ethical approval. the related articles frequently cited biomedical researchers or medical professionals. This frame is similar to the medical frame proposed by Results Clarke and Everest [21], which “depicted cancer as a physi- ologically based pathology explained and discussed within Nine Cancer Frames biomedicine.” The frame is characterized by reference to aspects like genes, cells, organs, medications etc. and is pri- Integrating previous research and our own analysis of can- marily delimited by the epidemiological and environmental cer-related newspaper articles, we identified nine distinc - frames (below). As elaborated by Clarke and Everest [21], tive cancer frames (Table 1). The frames were specifically the biomedical framing tends to treat cancer as a technical classified by how they contextualize the concept of cancer, Table 1 Classification of cancer frames Frame Presenting cancer Keywords Biomedical As a biological phenomenon, using scientific and medical Genetics, gene, mutations, anatomy, cells, tumor, organ, terminology growth, chemo, medication, therapy Epidemiologic At the level of populations and public health in terms of Risk, survival, prognosis, incidence, screening statistics Environmental As an environmentally caused phenomenon, related to expo- Cause, prevent, smoking, alcohol, diet, pollution, radiation, sure or lifestyle toxic Personal As a personal and psychological issue focusing on the perspec- I, family, grief, pain, anxiety, loss, remorse tive of the individual, family, and friends Sociopolitical As a social or political issue, including cultural, educational, Equality, stigma, gender, race, prejudice, responsibility, and ethical aspects campaign Economic As a financial issue, including health economics, fundraising, Cost, financial, funding, industry, company research funding, and business Alternative In terms of New Age, anti-establishment, pseudoscience, Energy, healing, power, vibrations, luck, paleo diet, herbs supernatural, and serendipity Antagonist As an adversary or challenge Fight, beat, kill, win, lose, war, battle, enemy, intruder, aggressor Symbolic As a metaphor or simile for something very bad Infectious, evil, invasive, spreading 1 3 Journal of Cancer Education (2022) 37:1918–1927 1921 problem. It emphasizes treatment rather than prevention and concerning aspects related to responsibility, blame, or shame is typically focused on solving the problem of cancer. of cancer is instead encompassed by the personal and the sociopolitical frame (below). The Epidemiological Frame Some articles presented can- cer in terms of numbers and statistics, typically related to The Personal Frame Many articles focused on personal and different groups and populations. Such accounts often con - psychological aspects, regarding cancer from the perspec- cerned incidence and prevalence: “Around 10,300 cases tive of individual patients and their families: “The family of bladder cancer are diagnosed every year among the UK slowly began to adjust to life with Angie’s cancer hanging population” (DM083). There were also frequent presenta- over them” (GU098), “‘Cancer never occurred to me,’ she tions of prognosis: “Around 50 to 60 per cent are alive after recalls today, four years later. ‘I was 36, I had two young three years and in the patients alive after five years there is children and in the space of a few days my life had changed a chance that the cancer will never return” (DM005). Some forever’” (DM086). concerned cancer risk factors: “Men over 50 and men with This way of framing cancer is similar to the personal sto- a family history of prostate cancer also face a higher than ries frame of Andsager and Powers [18] and Park and Reber average risk of the disease” (GU032). Others concerned [19] and also encompasses frames and themes which present screening and early detection: “early detection and treat- cancer as a personal fight, a test of character, a journey of ment through cervical screening in the UK can prevent up to growth, or simply as an arduous experience [23]. The per- 75% of cervical cancers from developing” (GU001). Finally, sonal frame is defined by discourse that describes cancer as there were articles that related cancer to the aging popula- a personal matter, often related to psychological distress and tion: “Most cancers are a result of ageing as people are less interpersonal relations. It regards cancer in terms of experi- likely to die from infectious diseases and advances in medi- ence and emotions and contrasts the scientific and reduction - cal science are keeping more alive after heart attacks and ist perspectives of the three above described frames. strokes and with other medical problems” (GU083). This frame is characterized by how it regards cancer in The Sociopolitical Frame Some of the newspaper articles terms of numbers and distribution in populations. It bears framed cancer as a societal and/or political problem, for some resemblance to the basic information frame of And- example, related to social disparities concerning age, gender, sager and Powers [18] but is more narrowly defined by its and socioeconomic status: “There are generational issues. quantitative and statistical aspects. It is further delineated Young women are quite comfortable about talking about this by the biomedical and the environmental frame. The epide- whereas the older generation aren’t” (DM058); “Boys are miological frame draws attention to the size of the cancer being denied protection against the risk of cancer because problem. It regards life and death in terms of numbers and they are not routinely offered the same vaccination as girls” is also unique in how it explains the cancer epidemic as a (GU082). Other articles concerned stigma and prejudice: consequence of the aging population. “Twenty years ago people never mentioned the ‘c’ word” (GU074); “One patient I heard about told her friends she had The Environmental Frame Some articles could be char- breast cancer rather than lung cancer, because breast cancer acterized by how they attributed cancer to environmental was so much more acceptable and less judged” (GU067). factors, either related to lifestyle or more involuntary expo- There were accounts of the ethical problems of cancer: “Do sure to carcinogens: “The council wants sunbed salons to the criteria of seriousness imply that people who get can- be regulated, to help halt the worrying rise of skin cancer” cer at the age of 20 or 80 are assured the same treatment?” (DM088); “…a study which found an association between (AF046). There were examples of how cancer is affected by pesticide use and non-Hodgkin lymphoma” (GU006). Such social interactions: “The researchers said a watchful husband articles describe behavior or exposure that promote or pro- or wife made it easier to catch the disease early” (DM089). tect against cancer development, typically including factors There were overarching political aspects: “This all reflects like smoking, diet, sun-tanning, alcohol, and pesticides. a system that’s failing to meet the needs of people with can- Clarke and Everest [21] have previously proposed a life- cer or suspected cancer” (GU019). And finally, there were style and a political/economy frame, which both encompass accounts related to population health initiatives: “What can elements of environmental causality. However, while these we do to make more black men understand the added danger frames focus on individual and societal responsibility, we they face and take the necessary action that could save their propose a unified environmental frame specifically defined lives?” (GU023). as discourse that relates cancer to environmental causes. Combined, this way of framing cancer is characterized This frame encompasses inadvertent exposures to carcino- by its relations to aspects like social disparities, stigma, gens as well as lifestyle-related factors like diet, smoking, prejudice, social structures, social responsibility, and poli- and lack of exercise, regardless of responsibility. Discourse tics. It contains elements from the political/economy frame 1 3 1922 Journal of Cancer Education (2022) 37:1918–1927 proposed by Clarke and Everest [21] and the social support/ for that pill are probably already right there on your kitchen educational and social/economic/political frame of Park and shelves” (DM038). Reber [19], and we recognize that there are several different Spanning from New Age philosophy to traditional reli- ways to combine and subcategorize these different elements. gious considerations and more causal superstition, this way However, aiming for simple definitions and distinct delimi - of framing cancer is defined by its metaphysical, mystical, or tations, we concluded on a combined sociopolitical frame, pseudoscientific perception of cancer. This alternative frame whereas all economic aspects were organized in a separate stands in contrast to the scientifically based discourse of the frame (below). biomedical, epidemiological, and environmental frame. It The macro perspective of the sociopolitical frame con- has a strong position in public discourse and poses a chal- trasts the individualized perspective of the personal frame. lenge to efforts to promote evidence-based understanding It regards cancer in a larger context and may as such be of cancer [3]. regarded as contrary to the reductionist perspective of the biomedical frame. The elevated point of view is somewhat The Antagonistic Frame Consistent with previous research, similar to the epidemiological frame, but instead of present- we found ample use of conflict metaphors in the material ing statistics, it focuses on the conflicts and dilemmas of of newspaper articles. Such accounts often concerned indi- cancer. vidual cancer patients: “Sir Michael Parkinson is winning his battle with prostate cancer” (SU092); “I don’t plan to The Economic Frame Many of the articles presented can- give up without a fight” (SU039). Some also deliberated on cer as an economic issue. This frame was primarily related the matter: “Marshall dislikes the ‘battle with cancer’ nar- to cancer’s cost for either the patient or the public health rative, and is loathe to describe her relationship with it as system: “Nivomulab costs around 60,000 to 100,000 lb a such. ‘I know it’s a cliché, but I would rather die standing year for a lung cancer patient” (DM022); “Many people than live on my knees’” (GU064). Other articles presented with cancer will feel cold and lonely due to the disease’s cancer as a fight within the body, often in combination with financial impact” (SU044). Another economic perspective the biomedical frame: “Her team is now hoping that it can concerned charity and fundraising: “the fundraising director identify how cancer hijacks the body’s cells, and develop at the cancer charity Antony Nolan, said: ‘Hopefully we’ll treatments which would destruct cancer cells without harm- raise over £600,000 and have over 255 runners’” (GU030). ing healthy cells” (SU057); “immunotherapy […] works by Other articles looked at cancer from the perspective of the ‘switching on’ the body’s immune system to fight cancer pharmaceutical industry: “The firm also signed a clinical cells” (DM005). Finally, there were articles that depicted trial collaboration with the Japan’s Kyowa Hakko Kirin for cancer as a fight at the societal and political level: “It is up a study that will assess combinations of the two companies’ to us in the community to act […] Ignoring cancer won’t cancer immunotherapy treatments” (GU072). beat it” (GU023). This economic frame views the cancer in terms of finan - Overall, we found that cancer was framed as an adversary cial resources, fundraising, and business development. It is in several different contexts, often in combination with other closely related to the sociopolitical frame (above) but at the frames (elaborated below). This kind of framing has been same time easily distinguished by its pecuniary perspective. criticized for promoting unrealistic expectations, disempow- Moreover, a separately defined economic frame emphasizes ering patients, and undermining preventative behaviors [22]. the enormous economic implication of cancer [2]. Concurrently, the antagonistic frame is a powerful tool for rallying support and sympathy, at the individual as well as The Alternative Frame Some articles included perceptions the political level, and there are valid arguments for framing which to varying degrees departed from established scien- cancer as an enemy, also from a biological perspective. This tific understandings of cancer. Some gave alternative expla - frame has a prominent position in public cancer discourse, nations for the cause of cancer: “If I was going to attribute and its conflicting function calls for special attention. my prostate cancer to anything, it would be that my body energy vibration, the balance of my body, was wrecked by The Symbolic Frame Some articles used the concept of can- what was going on” (DM032). Others made claims about cer as a symbol to describe something else. Typically, they alternative therapies: “[T]he spice [turmeric] may play a sig- applied cancer in metaphors or similes to describe other enti- nificant role in preventing or treating lung disease, brain dis - ties or phenomena as evil, invasive, or spreading: “Corrup- ease and a variety of cancers – including multiple myeloma, tion can no longer be described as a cancer on the system: it colon cancer and pancreatic cancer” (DM038). There were is the system” (DM034); “this new censorship is spreading also allusions to skepticism towards the mainstream medi- like a cancer across British universities” (DM045). cal and pharmaceutical industries: “I have news that Big This symbolic frame uses the concept of cancer to Pharma doesn’t particularly want to hear. The ingredients describe something else and is thus different from discourse 1 3 Journal of Cancer Education (2022) 37:1918–1927 1923 that uses metaphors to describe cancer [3]. It is also categor- Some frame combinations did not modify meaning but ically different from all the other frames since the discourse were associated because of thematic relationship. The epi- is not actually about cancer. Nevertheless, we concluded that demiological, sociopolitical, and economic frames all pre- the symbolic frame represents an aspect that both reflects sented the issue of cancer at the level of population and and influences people’s perception of cancer. It may rein - society, and their permutations tended to converge to a force the negative connotations of the disease and contribute public health perspective. In one article, for example, the to further stigmatization of patients. Although it is not a epidemiological frame was used to demonstrate the quantita- framing of cancer per se, we thus argue that the symbolic tive scope of cancer, and the economic frame related those frame belongs in a comprehensive scheme for analyzing numbers to financial implications, while the sociopolitical cancer discourse. frame used the unfavorable scenario as grounds to campaign for improvements of care (Fig. 1). Similarly, the environ- mental frame was often accompanied by epidemiological Frame Combinations information, typically to substantiate links between exposure and cancer risk (Fig. 2). Whereas framing analysis often aims to identify a dominant Other frames were inherently distinct but complemented frame for each article, the above described framing scheme one another to produce synergic effects. For example, allows for a more detailed analysis. Many of the articles in predominantly biomedically framed articles sometimes the material included more than one cancer frame, and the included elements of the personal frame, making scientific analysis revealed how frames combined to produce more information more relatable: “Radiotherapy can be effective, complex messages. but there is a risk of damaging healthy tissue. However, a Some frames combined to evoke a new composite mean- highly-targeted treatment can zap the tumour in just five ing. For instance, the antagonistic frame combined with the days, leaving surrounding organs intact. Dr John Sheehy, biomedical frame to present cancer as a tangible enemy, 70, a scientist from Marlow, Buckinghamshire, underwent which is fought with biotechnology: “[I]mmunotherapy the therapy” (DM090). Conversely, elements of the biomedi- […] works by ‘switching on’ the body’s immune system to cal frame added authority and factual substance to personal fight cancer cells” (DM005). In other cases, the antagonistic stories about cancer: “If I’d hoped my cancer was early stage frame combined with the sociopolitical and economic frame and non-invasive, my follow-up appointment that Friday to present cancer as a public enemy. This combination typi- revealed a different story […] It was likely to be grade two cally reflected the war on cancer mentality, often aiming or three, depending on whether he discovered a spread to my for a cure and often appearing in articles calling on people lymph nodes during my mastectomy” (DM056). to promote research funding and donate to cancer charities: “[W]ith YOUR help, you could help us smash our £1million target […] helping scientists make positive steps towards a Discussion cure” (SU028). Similarly, the antagonistic frame combined with the personal frame to present the psychological hard- In this study, we have developed an applicable tool for ana- ship of cancer: “[H]e had ‘fought the constant recurrences lyzing cancer communication. Specifically, we have identi - of his cancer with dogged courage’” (GU095). fied and categorized nine different cancer frames, which may Another combinatory modification was seen for the be recognized in cancer discourse across different themes alternative frame. Combining the alternative frame with and context. This unified framing scheme may be used in the personal frame typically presented cancer as a spirit- education and further research to facilitate cancer literacy. ual and metaphysical phenomenon: “[H]e’d ask a child if The analyzed material of newspaper articles was limited their cancer was caused by negative energy” (DM032). Con- to the recent 5-year period and a Western European con- versely, the alternative frame combined with the biomedi- text, and there may be historical or cultural aspects to cancer cal and environmental frame to compose a pseudoscientific that are missing. Moreover, this qualitative, largely induc- message: “Ounce for ounce, herbs and spices have more tive study aimed to identify and characterize a set of frames antioxidants than any other food group. This means they based on obtaining consensus between the coders and does can help prevent the initial triggering of mutations in your not include an assessment of inter-coder reliability. A deduc- DNA that could lead to cancer or other diseases” (DM046). tive analysis, for example, to explore differences between These combined messages have varying degrees of scien- countries or media sources, will require a quantitative design tific validity. They may be difficult to recognize and assess, and is deferred to future studies. without expert knowledge, and deciphering and countering We also acknowledge that our framing scheme is merely such pseudoscientific discourses represent a key challenge one of several possible ways to classify public cancer dis- in cancer communication. course and that different framing schemes address different 1 3 1924 Journal of Cancer Education (2022) 37:1918–1927 Fig. 1 This article combines the thematically related sociopo- litical frame (magenta) and epidemiological frame (yellow) to present a public health per- spective. Notice also a limited account of the biomedical frame (blue), which complements the public health perspective with information about the underly- ing biology and pathology of cancer problems of communication. Yet, for the purpose of devel- specifically concerns the statistical and population-based oping a simple framework that may be used for educational aspects of the disease. These frames are further defined by purposes, to analyze cancer discourse across themes and top- their distinction from the biomedical frame, which concerns ics, we believe that this framing scheme represents a sensible the biological, diagnostic, and therapeutic aspects of cancer. balance between simplicity and discriminatory power. Another novel feature of the presented framing scheme is Whereas the nine frames are related to previously the ability to identify and explore a variety of frame combi- described frames, there are also important differences. The nations. The use of one frame may be modified, reinforced, antagonistic frame is clearly related to the vast literature or complemented by other frames, and an article may rep- (here represented by [3, 22]) which has analyzed and dis- resent different permutations of the nine frames. The fram - cussed the use of war metaphors in cancer discourse. Con- ing scheme may thus be used to dissect composite framing currently, however, we identified a clear distinction between effects in more complex messages. Such analysis may reveal this frame and a symbolic frame, which applies the word the underlying strategies or conflicts in cancer communica - cancer as a metaphor or simile. Whereas the antagonistic tion, which may be difficult to identify without a compre - frame presents cancer as an enemy, the symbolic frame uses hensive framing scheme. the concept of cancer to characterize something else (e.g., Combined, the nine cancer frames may be used as a corruption or Islamism) as a malicious foe. tool for cancer education. The concept of framing, and We also identified an environmental frame, clearly how it affects communication, is quite easy to understand defined by how it attributes cancer to exposure and life - and may be applied to different levels of education, from style-related factors, and an epidemiological frame, which secondary school to PhD courses. As demonstrated by 1 3 Journal of Cancer Education (2022) 37:1918–1927 1925 Fig. 2 This article primarily combines the epidemiological frame (yellow) and the environ- mental frame (green) to form a prevention-oriented public health perspective. Towards the end, it then switches to the sociopolitical (magenta) and economic (violet) frame, appealing for more cancer research, emphasizing the grow- ing cost of cancer for society and the need for change in the healthcare system Carver et al. [25], a set of clearly defined frames was used Groups of students may be presented with the framing as an educational tool that enabled students to analyze scheme and asked to identify which frames are used in dif- and explore genetic discourse in a systematic manner, ferent media articles [25]. Each frame may be assigned a which prompted scientific understanding as well as media specific color, as demonstrated in Figs.  1 and 2, and the stu- literacy. Similarly, the above presented framing scheme dents are provided highlighter pens to mark the correspond- is especially relevant for an interdisciplinary educational ing sections of the text. 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Kruijff S, Van Zweden C (2017) The harmful impact of the rheto - ric “war on cancer.” Eur J Surg Oncol 43(6):963–964 1 3 Journal of Cancer Education (2022) 37:1918–1927 1927 23. Bell K (2012) Remaking the self: trauma, teachable moments, J Sci Educ Part B 4(3):211–239. https://doi-org.ezproxy.uio. and the biopolitics of cancer survivorship. Cult Med Psychiatry no/10.1080/21548455.2013.797128 36(4):584–600 24. Carver RB, Rødland EA, Breivik J (2013) Quantitative frame Publisher’s Note Springer Nature remains neutral with regard to analysis of how the gene concept is presented in tabloid and elite jurisdictional claims in published maps and institutional affiliations. newspapers. Sci Commun 35(4):449–475 25. Carver RB, Wiese EF, Breivik J (2014) Frame analy- sis in science education: a classroom activity for promot- ing media literacy and learning about genetic causation. Int 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

The Nine Cancer Frames: A Tool to Facilitate Critical Reading of Cancer-Related Information

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Springer Journals
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Copyright © The Author(s) 2021
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10.1007/s13187-021-02062-7
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Abstract

People’s ability to critically assess cancer-related information is essential from a preventional and therapeutic, as well as a general democratic perspective. Such cancer literacy is not just about acquiring factual knowledge. It also involves the abil- ity to analyze how the information is contextualized—how cancer is framed. Previous research concerning the framing of cancer in public discourse is voluminous and penetrating but also fragmented and inaccessible to non-experts. In this study, we have developed an integrated and applicable tool for analyzing cancer discourse by systematically classifying distinctive ways of framing of the concept of cancer. Building on previous research and an inductive framing analysis of a broad range of public cancer discourse, systematically selected from British and Norwegian newspapers, we have characterized nine cancer frames: the biomedical, the environmental, the epidemiological, the personal, the sociopolitical, the economic, the antagonistic, the alternative, and the symbolic frame. This framing scheme may be applied to analyze cancer-related discourse across a plurality of themes and contexts. We also show how different frames combine to produce more complex messages, thereby revealing underlying patterns, strategies, and conflicts in cancer communication. In conclusion, this analytical tool enables critical reading of cancer-related information and may be especially useful in educational initiatives to advance health communication and public understanding of cancer. Keywords Cancer communication · Framing analysis · Health literacy · Mass media · Social science · Medicine · UK · Norway Introduction At the individual level, the word cancer is laden with fear and stigma [3]. Cancer prevention, screening, and therapy Cancer literacy, meaning people’s ability to critically assess involve difficult questions related to ethics and equality [ 4, cancer-related information, is increasingly important. Over- 5], and people’s understanding of these issues has imme- all cancer incidence and prevalence are rising, primarily diate effects on health awareness, care-seeking behavior, because of an aging population [1]. The worldwide annual and engagement in screening programs [6, 7]. How patients cost of cancer is estimated to more than US$ 1 trillion. Can- understand cancer influences how they relate to the disease cer therapy is a booming industry, and cancer research is and potentially its course of development, their quality of a major driver of the ongoing biotechnological revolution life, and even survival [8, 9]. [2]. To assure democratic decision-making and develop- Overall, there is a strong need for tools and methods that ment, there is thus a strong need for the general population facilitate the development of cancer literacy. People should to understand cancer and its impact on society. be able to critically assess cancer-related information from difference sources, especially the wide range of content provided by the mass media. Besides formal education, the * Jarle Breivik media represent the public’s primary source of information jarle.breivik@medisin.uio.no regarding health and science [10, 11]. TV and online news Department of Behavioural Medicine, Institute of Basic channels convey the voices of patients, researchers, health- Medical Sciences, Faculty of Medicine, University of Oslo, care providers, and public institutions, and the media both Blindern, P.O.Box 1111, N-0317 Oslo, Norway shape and reflect public understanding of cancer. National Resource Centre for Late Effects After Cancer Treatment, Oslo University Hospital, Oslo, Norway 1 3 Journal of Cancer Education (2022) 37:1918–1927 1919 Developing cancer literacy is not just a matter of acquir- aspects of cancer discourse. In this study, therefore, we have ing factual knowledge about the relevant issues. It also developed a unified framing scheme, which facilitates criti - involves the ability to analyze how the information is cal reading of cancer-related information across a wide range contextualized. To make sense of cancer—or any other of themes and context. issue—information has to be organized into an intellectual framework; it has to be framed [12, 13]. When people com- municate, they frame their stories by using certain words, facts, depictions, metaphors, sources of information, and Material and Methods images. Accordingly, a particular concept may be presented or described in ways that communicate different meanings. Drawing on the seminal work of Goffman [ 12], we regard frames as “schemata of interpretation” by which people A gene, for example, may be framed as a physical entity, a risk factor, or a symbol of relationship, depending on the make sense of issues and events. Further elaborated by Ent- man [22], these mental frames are embodied in the key- context and the purpose of the communication [14]. Each frame conveys a different interpretation of reality [ 15], and words, metaphors, concepts, symbols, and visual images represented in different items of communication. framing analysis is a powerful tool, in research as well as education, for exploring the underlying process of commu- Framing analysis is the process of identifying and explor- ing such frames and may be either a qualitative or quan- nication [16]. Many studies have investigated the framing of cancer- titative method. For this study, we applied a qualitative approach, looking to characterize how the concept of cancer related discourse. Some have focused on a single issue and identified narrow, issue-specific frames. Kolker [17], for is framed from a newly selected material. The process was primarily inductive, but it was also informed by the literature example, found that patient advocacy groups frame breast cancer as an epidemic, a problem of gender equality, or outlined above. To validate, refine, and supplement previ - ous research in the field, we set out to analyze a wide body a threat to families. Others have identified more generic frames, including conflict , human impact, and economic of public discourse concerning cancer, and we found that a broad selection of online newspaper articles represented consequences, or episodic versus thematic news frames. Andsager and Powers categorized breast cancer coverage a pertinent source of information. Including news reports, interviews, features, editorials, commentaries, book reviews, into a basic information, a research, and a personal stories frame [18], whereas Park and Reber added a social support/ and informational articles about health and science, this material conveyed many different societal voices and rep - educational frame and a social/economic/political frame to this scheme [19]. resented a comprehensive selection of cancer-related infor- mation. Moreover, online newspaper articles represented Other studies have identified frames based on how mass media discourse attributes responsibility for the causes and an easily definable material, readily available in searchable databases, also for scrutiny by other researchers. solutions of cancer [20]. Clarke and Everest divided cancer- related news into a lifestyle frame, which focuses on individ- To gain insight into the contemporary European context in two different languages, we chose to analyze leading daily ual responsibility and solutions; a political/economy frame, which emphasizes the corresponding societal aspects; and a newspapers from the UK and Norway in the period from 2013 to 2018. To increase representativeness of the study medical frame, which underscores biological explanations and biomedical solutions [21]. regarding the entire landscape of journalistic styles and the respective socioeconomic readerships, we included equal Another focus of research concerns the use of metaphors. Many studies have addressed the use of war metaphors and numbers of articles from an elite, a mid-market, and a tab- loid newspaper from each country. Respectively, we selected the depiction of cancer as an enemy [22]. Sontag also dem- onstrated how cancer often functions as a metaphor for both The Guardian (GU), the Daily Mail (DM), and The Sun (SU) from the UK, and Aftenposten (AF), Dagbladet (DB), and monstrosity and uncontrolled growth, whereas Sontag [3] and others have discussed a mystical, alternative, and New Verdens Gang (VG) from Norway, building on the previous classification by Carver et al. [ 24]. Age perspective to cancer. Finally, multiple studies have described how cancer is presented from a personal and psy- Cancer-related articles were retrieved from the electronic databases Factiva (UK) and Atekst (Norway) by searching chological perspective, tending to describe the experience as a journey, heroic struggle, or test of character [23]. for cancer and kreft, respectively. To achieve a sample, both random and balanced, over the entire time period, the In summary, the literature on the framing of cancer dis- course is rich and insightful but also quite fragmented and resulting lists of articles for each newspaper were sorted by date, and 100 articles per newspaper were selected at regular inaccessible to the general public. We find no study that combines the different frames, perspectives, and metaphors intervals. Irrelevant results referring to the cancer zodiac or passing mentions of the word cancer, for example, in the in an applicable educational tool for analyzing the contextual 1 3 1920 Journal of Cancer Education (2022) 37:1918–1927 name of an organization, were excluded and replaced by the and we here present the characteristics of each frame and subsequent article in the list. how it is differentiated from the other frames: Using previously described frames and metaphors as a starting point, we then conducted a systematic framing The Biomedical Frame An obvious and intuitive way of analysis of the 600 articles. The three coders (N.P., C.M., framing cancer is to present it as a disease: a biomedical J.B.) began analyzing identical sets of five articles, address - problem characterized by the uncontrolled growth and ing the question: what kind of problem or issue is cancer spread of cells within the body, similar to how cancer is according to this article? Recognizing that one article could presented in a textbook of pathology. This frame was also comprise several cancer frames, we highlighted which text prevalent in our material of newspaper articles. These arti- corresponded to which nascent frame, subsequently compar- cles focused on the physical and technical aspects of cancer ing and discussing coding until consensus. and cancer treatment: “Its growth is driven by cancerous After five such rounds of coding, a clear pattern started to stem cells that are resistant to chemotherapy and radiation” emerge, and for the rest of the material, we only discussed (DM008). “Researchers have found the MC1R gene vari- articles that the coders identified as ambiguous or incompat - ant increases the number of mutations in skin cancer cells, ible to our previous classifications. Aiming to develop an multiplying the risk” (SU030). applicable educational tool, we sought a pragmatic balance Such articles typically described cancer at the level of between a framing scheme sensitive to the nuances of cancer cells, organs, or the body system, often in terms of genetic discourse and one that was easy to explain and simple to use. mutations and biological mechanisms. They depicted cancer Throughout the process, we also compared the emerging as a biological phenomenon, a tumor or growth that might frames with trends and perspectives identified in previous spread, invade, or metastasize and could also present infor- research (presented above). mation about symptoms, diagnostics, and therapeutic prin- The study did not involve human subjects or sensitive ciples. The topic was often related to cancer research, and information and required no ethical approval. the related articles frequently cited biomedical researchers or medical professionals. This frame is similar to the medical frame proposed by Results Clarke and Everest [21], which “depicted cancer as a physi- ologically based pathology explained and discussed within Nine Cancer Frames biomedicine.” The frame is characterized by reference to aspects like genes, cells, organs, medications etc. and is pri- Integrating previous research and our own analysis of can- marily delimited by the epidemiological and environmental cer-related newspaper articles, we identified nine distinc - frames (below). As elaborated by Clarke and Everest [21], tive cancer frames (Table 1). The frames were specifically the biomedical framing tends to treat cancer as a technical classified by how they contextualize the concept of cancer, Table 1 Classification of cancer frames Frame Presenting cancer Keywords Biomedical As a biological phenomenon, using scientific and medical Genetics, gene, mutations, anatomy, cells, tumor, organ, terminology growth, chemo, medication, therapy Epidemiologic At the level of populations and public health in terms of Risk, survival, prognosis, incidence, screening statistics Environmental As an environmentally caused phenomenon, related to expo- Cause, prevent, smoking, alcohol, diet, pollution, radiation, sure or lifestyle toxic Personal As a personal and psychological issue focusing on the perspec- I, family, grief, pain, anxiety, loss, remorse tive of the individual, family, and friends Sociopolitical As a social or political issue, including cultural, educational, Equality, stigma, gender, race, prejudice, responsibility, and ethical aspects campaign Economic As a financial issue, including health economics, fundraising, Cost, financial, funding, industry, company research funding, and business Alternative In terms of New Age, anti-establishment, pseudoscience, Energy, healing, power, vibrations, luck, paleo diet, herbs supernatural, and serendipity Antagonist As an adversary or challenge Fight, beat, kill, win, lose, war, battle, enemy, intruder, aggressor Symbolic As a metaphor or simile for something very bad Infectious, evil, invasive, spreading 1 3 Journal of Cancer Education (2022) 37:1918–1927 1921 problem. It emphasizes treatment rather than prevention and concerning aspects related to responsibility, blame, or shame is typically focused on solving the problem of cancer. of cancer is instead encompassed by the personal and the sociopolitical frame (below). The Epidemiological Frame Some articles presented can- cer in terms of numbers and statistics, typically related to The Personal Frame Many articles focused on personal and different groups and populations. Such accounts often con - psychological aspects, regarding cancer from the perspec- cerned incidence and prevalence: “Around 10,300 cases tive of individual patients and their families: “The family of bladder cancer are diagnosed every year among the UK slowly began to adjust to life with Angie’s cancer hanging population” (DM083). There were also frequent presenta- over them” (GU098), “‘Cancer never occurred to me,’ she tions of prognosis: “Around 50 to 60 per cent are alive after recalls today, four years later. ‘I was 36, I had two young three years and in the patients alive after five years there is children and in the space of a few days my life had changed a chance that the cancer will never return” (DM005). Some forever’” (DM086). concerned cancer risk factors: “Men over 50 and men with This way of framing cancer is similar to the personal sto- a family history of prostate cancer also face a higher than ries frame of Andsager and Powers [18] and Park and Reber average risk of the disease” (GU032). Others concerned [19] and also encompasses frames and themes which present screening and early detection: “early detection and treat- cancer as a personal fight, a test of character, a journey of ment through cervical screening in the UK can prevent up to growth, or simply as an arduous experience [23]. The per- 75% of cervical cancers from developing” (GU001). Finally, sonal frame is defined by discourse that describes cancer as there were articles that related cancer to the aging popula- a personal matter, often related to psychological distress and tion: “Most cancers are a result of ageing as people are less interpersonal relations. It regards cancer in terms of experi- likely to die from infectious diseases and advances in medi- ence and emotions and contrasts the scientific and reduction - cal science are keeping more alive after heart attacks and ist perspectives of the three above described frames. strokes and with other medical problems” (GU083). This frame is characterized by how it regards cancer in The Sociopolitical Frame Some of the newspaper articles terms of numbers and distribution in populations. It bears framed cancer as a societal and/or political problem, for some resemblance to the basic information frame of And- example, related to social disparities concerning age, gender, sager and Powers [18] but is more narrowly defined by its and socioeconomic status: “There are generational issues. quantitative and statistical aspects. It is further delineated Young women are quite comfortable about talking about this by the biomedical and the environmental frame. The epide- whereas the older generation aren’t” (DM058); “Boys are miological frame draws attention to the size of the cancer being denied protection against the risk of cancer because problem. It regards life and death in terms of numbers and they are not routinely offered the same vaccination as girls” is also unique in how it explains the cancer epidemic as a (GU082). Other articles concerned stigma and prejudice: consequence of the aging population. “Twenty years ago people never mentioned the ‘c’ word” (GU074); “One patient I heard about told her friends she had The Environmental Frame Some articles could be char- breast cancer rather than lung cancer, because breast cancer acterized by how they attributed cancer to environmental was so much more acceptable and less judged” (GU067). factors, either related to lifestyle or more involuntary expo- There were accounts of the ethical problems of cancer: “Do sure to carcinogens: “The council wants sunbed salons to the criteria of seriousness imply that people who get can- be regulated, to help halt the worrying rise of skin cancer” cer at the age of 20 or 80 are assured the same treatment?” (DM088); “…a study which found an association between (AF046). There were examples of how cancer is affected by pesticide use and non-Hodgkin lymphoma” (GU006). Such social interactions: “The researchers said a watchful husband articles describe behavior or exposure that promote or pro- or wife made it easier to catch the disease early” (DM089). tect against cancer development, typically including factors There were overarching political aspects: “This all reflects like smoking, diet, sun-tanning, alcohol, and pesticides. a system that’s failing to meet the needs of people with can- Clarke and Everest [21] have previously proposed a life- cer or suspected cancer” (GU019). And finally, there were style and a political/economy frame, which both encompass accounts related to population health initiatives: “What can elements of environmental causality. However, while these we do to make more black men understand the added danger frames focus on individual and societal responsibility, we they face and take the necessary action that could save their propose a unified environmental frame specifically defined lives?” (GU023). as discourse that relates cancer to environmental causes. Combined, this way of framing cancer is characterized This frame encompasses inadvertent exposures to carcino- by its relations to aspects like social disparities, stigma, gens as well as lifestyle-related factors like diet, smoking, prejudice, social structures, social responsibility, and poli- and lack of exercise, regardless of responsibility. Discourse tics. It contains elements from the political/economy frame 1 3 1922 Journal of Cancer Education (2022) 37:1918–1927 proposed by Clarke and Everest [21] and the social support/ for that pill are probably already right there on your kitchen educational and social/economic/political frame of Park and shelves” (DM038). Reber [19], and we recognize that there are several different Spanning from New Age philosophy to traditional reli- ways to combine and subcategorize these different elements. gious considerations and more causal superstition, this way However, aiming for simple definitions and distinct delimi - of framing cancer is defined by its metaphysical, mystical, or tations, we concluded on a combined sociopolitical frame, pseudoscientific perception of cancer. This alternative frame whereas all economic aspects were organized in a separate stands in contrast to the scientifically based discourse of the frame (below). biomedical, epidemiological, and environmental frame. It The macro perspective of the sociopolitical frame con- has a strong position in public discourse and poses a chal- trasts the individualized perspective of the personal frame. lenge to efforts to promote evidence-based understanding It regards cancer in a larger context and may as such be of cancer [3]. regarded as contrary to the reductionist perspective of the biomedical frame. The elevated point of view is somewhat The Antagonistic Frame Consistent with previous research, similar to the epidemiological frame, but instead of present- we found ample use of conflict metaphors in the material ing statistics, it focuses on the conflicts and dilemmas of of newspaper articles. Such accounts often concerned indi- cancer. vidual cancer patients: “Sir Michael Parkinson is winning his battle with prostate cancer” (SU092); “I don’t plan to The Economic Frame Many of the articles presented can- give up without a fight” (SU039). Some also deliberated on cer as an economic issue. This frame was primarily related the matter: “Marshall dislikes the ‘battle with cancer’ nar- to cancer’s cost for either the patient or the public health rative, and is loathe to describe her relationship with it as system: “Nivomulab costs around 60,000 to 100,000 lb a such. ‘I know it’s a cliché, but I would rather die standing year for a lung cancer patient” (DM022); “Many people than live on my knees’” (GU064). Other articles presented with cancer will feel cold and lonely due to the disease’s cancer as a fight within the body, often in combination with financial impact” (SU044). Another economic perspective the biomedical frame: “Her team is now hoping that it can concerned charity and fundraising: “the fundraising director identify how cancer hijacks the body’s cells, and develop at the cancer charity Antony Nolan, said: ‘Hopefully we’ll treatments which would destruct cancer cells without harm- raise over £600,000 and have over 255 runners’” (GU030). ing healthy cells” (SU057); “immunotherapy […] works by Other articles looked at cancer from the perspective of the ‘switching on’ the body’s immune system to fight cancer pharmaceutical industry: “The firm also signed a clinical cells” (DM005). Finally, there were articles that depicted trial collaboration with the Japan’s Kyowa Hakko Kirin for cancer as a fight at the societal and political level: “It is up a study that will assess combinations of the two companies’ to us in the community to act […] Ignoring cancer won’t cancer immunotherapy treatments” (GU072). beat it” (GU023). This economic frame views the cancer in terms of finan - Overall, we found that cancer was framed as an adversary cial resources, fundraising, and business development. It is in several different contexts, often in combination with other closely related to the sociopolitical frame (above) but at the frames (elaborated below). This kind of framing has been same time easily distinguished by its pecuniary perspective. criticized for promoting unrealistic expectations, disempow- Moreover, a separately defined economic frame emphasizes ering patients, and undermining preventative behaviors [22]. the enormous economic implication of cancer [2]. Concurrently, the antagonistic frame is a powerful tool for rallying support and sympathy, at the individual as well as The Alternative Frame Some articles included perceptions the political level, and there are valid arguments for framing which to varying degrees departed from established scien- cancer as an enemy, also from a biological perspective. This tific understandings of cancer. Some gave alternative expla - frame has a prominent position in public cancer discourse, nations for the cause of cancer: “If I was going to attribute and its conflicting function calls for special attention. my prostate cancer to anything, it would be that my body energy vibration, the balance of my body, was wrecked by The Symbolic Frame Some articles used the concept of can- what was going on” (DM032). Others made claims about cer as a symbol to describe something else. Typically, they alternative therapies: “[T]he spice [turmeric] may play a sig- applied cancer in metaphors or similes to describe other enti- nificant role in preventing or treating lung disease, brain dis - ties or phenomena as evil, invasive, or spreading: “Corrup- ease and a variety of cancers – including multiple myeloma, tion can no longer be described as a cancer on the system: it colon cancer and pancreatic cancer” (DM038). There were is the system” (DM034); “this new censorship is spreading also allusions to skepticism towards the mainstream medi- like a cancer across British universities” (DM045). cal and pharmaceutical industries: “I have news that Big This symbolic frame uses the concept of cancer to Pharma doesn’t particularly want to hear. The ingredients describe something else and is thus different from discourse 1 3 Journal of Cancer Education (2022) 37:1918–1927 1923 that uses metaphors to describe cancer [3]. It is also categor- Some frame combinations did not modify meaning but ically different from all the other frames since the discourse were associated because of thematic relationship. The epi- is not actually about cancer. Nevertheless, we concluded that demiological, sociopolitical, and economic frames all pre- the symbolic frame represents an aspect that both reflects sented the issue of cancer at the level of population and and influences people’s perception of cancer. It may rein - society, and their permutations tended to converge to a force the negative connotations of the disease and contribute public health perspective. In one article, for example, the to further stigmatization of patients. Although it is not a epidemiological frame was used to demonstrate the quantita- framing of cancer per se, we thus argue that the symbolic tive scope of cancer, and the economic frame related those frame belongs in a comprehensive scheme for analyzing numbers to financial implications, while the sociopolitical cancer discourse. frame used the unfavorable scenario as grounds to campaign for improvements of care (Fig. 1). Similarly, the environ- mental frame was often accompanied by epidemiological Frame Combinations information, typically to substantiate links between exposure and cancer risk (Fig. 2). Whereas framing analysis often aims to identify a dominant Other frames were inherently distinct but complemented frame for each article, the above described framing scheme one another to produce synergic effects. For example, allows for a more detailed analysis. Many of the articles in predominantly biomedically framed articles sometimes the material included more than one cancer frame, and the included elements of the personal frame, making scientific analysis revealed how frames combined to produce more information more relatable: “Radiotherapy can be effective, complex messages. but there is a risk of damaging healthy tissue. However, a Some frames combined to evoke a new composite mean- highly-targeted treatment can zap the tumour in just five ing. For instance, the antagonistic frame combined with the days, leaving surrounding organs intact. Dr John Sheehy, biomedical frame to present cancer as a tangible enemy, 70, a scientist from Marlow, Buckinghamshire, underwent which is fought with biotechnology: “[I]mmunotherapy the therapy” (DM090). Conversely, elements of the biomedi- […] works by ‘switching on’ the body’s immune system to cal frame added authority and factual substance to personal fight cancer cells” (DM005). In other cases, the antagonistic stories about cancer: “If I’d hoped my cancer was early stage frame combined with the sociopolitical and economic frame and non-invasive, my follow-up appointment that Friday to present cancer as a public enemy. This combination typi- revealed a different story […] It was likely to be grade two cally reflected the war on cancer mentality, often aiming or three, depending on whether he discovered a spread to my for a cure and often appearing in articles calling on people lymph nodes during my mastectomy” (DM056). to promote research funding and donate to cancer charities: “[W]ith YOUR help, you could help us smash our £1million target […] helping scientists make positive steps towards a Discussion cure” (SU028). Similarly, the antagonistic frame combined with the personal frame to present the psychological hard- In this study, we have developed an applicable tool for ana- ship of cancer: “[H]e had ‘fought the constant recurrences lyzing cancer communication. Specifically, we have identi - of his cancer with dogged courage’” (GU095). fied and categorized nine different cancer frames, which may Another combinatory modification was seen for the be recognized in cancer discourse across different themes alternative frame. Combining the alternative frame with and context. This unified framing scheme may be used in the personal frame typically presented cancer as a spirit- education and further research to facilitate cancer literacy. ual and metaphysical phenomenon: “[H]e’d ask a child if The analyzed material of newspaper articles was limited their cancer was caused by negative energy” (DM032). Con- to the recent 5-year period and a Western European con- versely, the alternative frame combined with the biomedi- text, and there may be historical or cultural aspects to cancer cal and environmental frame to compose a pseudoscientific that are missing. Moreover, this qualitative, largely induc- message: “Ounce for ounce, herbs and spices have more tive study aimed to identify and characterize a set of frames antioxidants than any other food group. This means they based on obtaining consensus between the coders and does can help prevent the initial triggering of mutations in your not include an assessment of inter-coder reliability. A deduc- DNA that could lead to cancer or other diseases” (DM046). tive analysis, for example, to explore differences between These combined messages have varying degrees of scien- countries or media sources, will require a quantitative design tific validity. They may be difficult to recognize and assess, and is deferred to future studies. without expert knowledge, and deciphering and countering We also acknowledge that our framing scheme is merely such pseudoscientific discourses represent a key challenge one of several possible ways to classify public cancer dis- in cancer communication. course and that different framing schemes address different 1 3 1924 Journal of Cancer Education (2022) 37:1918–1927 Fig. 1 This article combines the thematically related sociopo- litical frame (magenta) and epidemiological frame (yellow) to present a public health per- spective. Notice also a limited account of the biomedical frame (blue), which complements the public health perspective with information about the underly- ing biology and pathology of cancer problems of communication. Yet, for the purpose of devel- specifically concerns the statistical and population-based oping a simple framework that may be used for educational aspects of the disease. These frames are further defined by purposes, to analyze cancer discourse across themes and top- their distinction from the biomedical frame, which concerns ics, we believe that this framing scheme represents a sensible the biological, diagnostic, and therapeutic aspects of cancer. balance between simplicity and discriminatory power. Another novel feature of the presented framing scheme is Whereas the nine frames are related to previously the ability to identify and explore a variety of frame combi- described frames, there are also important differences. The nations. The use of one frame may be modified, reinforced, antagonistic frame is clearly related to the vast literature or complemented by other frames, and an article may rep- (here represented by [3, 22]) which has analyzed and dis- resent different permutations of the nine frames. The fram - cussed the use of war metaphors in cancer discourse. Con- ing scheme may thus be used to dissect composite framing currently, however, we identified a clear distinction between effects in more complex messages. Such analysis may reveal this frame and a symbolic frame, which applies the word the underlying strategies or conflicts in cancer communica - cancer as a metaphor or simile. Whereas the antagonistic tion, which may be difficult to identify without a compre - frame presents cancer as an enemy, the symbolic frame uses hensive framing scheme. the concept of cancer to characterize something else (e.g., Combined, the nine cancer frames may be used as a corruption or Islamism) as a malicious foe. tool for cancer education. The concept of framing, and We also identified an environmental frame, clearly how it affects communication, is quite easy to understand defined by how it attributes cancer to exposure and life - and may be applied to different levels of education, from style-related factors, and an epidemiological frame, which secondary school to PhD courses. As demonstrated by 1 3 Journal of Cancer Education (2022) 37:1918–1927 1925 Fig. 2 This article primarily combines the epidemiological frame (yellow) and the environ- mental frame (green) to form a prevention-oriented public health perspective. Towards the end, it then switches to the sociopolitical (magenta) and economic (violet) frame, appealing for more cancer research, emphasizing the grow- ing cost of cancer for society and the need for change in the healthcare system Carver et al. 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Journal

Journal of Cancer EducationSpringer Journals

Published: Dec 1, 2022

Keywords: Cancer communication; Framing analysis; Health literacy; Mass media; Social science; Medicine; UK; Norway

References