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AN EDUCATION FOR (FUTURE) HEALTH

PROFESSIONALS AND LITERARY SCHOLARS:

AUDRE LORDE’S THE CANCER JOURNALS

AND MARISA MARCHETTO’S CANCER VIXEN

UNA EDUCACIÓN PARA (FUTURAS/OS)

PROFESIONALES DE LA SALUD Y EXPERTAS/OS

EN LITERATURA: THE CANCER JOURNALS

DE AUDRE LORDE Y CANCER VIXEN

DE MARISA MARCHETTO

https://doi.org/10.26754/ojs_misc/mj.202410198

FRANCISCO JOSÉ CORTÉS VIECO

Universidad Complutense de Madrid

francort@pdi.ucm.es

<https://orcid.org/0000-0002-7280-6092>

Abstract

Life-writing on breast cancer vindicates women’s health rights, but, as this article

demonstrates, the autopathographies Cancer Journals (1980) by Audre Lorde

and Cancer Vixen (2006) by Marisa Marchetto also have the potential to teach

lessons to (future) health professionals and scholars in literary studies, so that

they can, respectively, improve their interactions with patients and understand

the therapeutic power of illness narratives to emotionally heal their authors and

intended female readers. Lorde uses the weapon of anger both to criticize how

cancer patients are dehumanized by the often-insensitive medical profession and

to proudly assert her post-mastectomy identity as a one-breasted warrior.

Meanwhile, Marchetto opts for humor to describe her eleven-month war against

breast cancer and its associated complications: her lack of health insurance to

treat her illness and her fear of losing her fiancé. Yet, as this article examines,

Cancer Vixen shows the illuminating power of graphic medicine as a breakthrough

narrative form, to mitigate the antagonism between doctors and cancer patients,

while enhancing literary scholars’ and health professionals’ empathic

understanding of patients’ personal stories of illness beyond clinical and hospital

encounters.

Keywords: breast cancer, diaries, graphic medicine, patient, health professionals.

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Resumen

Los testimonios de mujeres sobre el cáncer de mama reclaman su derecho a la

salud, pero como este ensayo demuestra, Cancer Journals (1980) de Audre Lorde

y Cancer Vixen (2006) de Marisa Marchetto igualmente enseñan lecciones a

(futuras/os) profesionales de la salud y a expertas/os en literatura para,

respectivamente, mejorar sus relaciones con las pacientes de cáncer y apreciar el

poder terapéutico de las autopatografías: la recuperación emocional de sus autoras

y lectoras. Lorde emplea el arma de la rabia para criticar que la profesión médica es

insensible y deshumaniza a la enferma de cáncer, además de afirmar, con orgullo,

su nueva identidad tras la mastectomía: guerrera con un solo pecho. En cambio,

Marchetto elige el humor para describir su batalla de once meses contra el cáncer

de mama y sus complicaciones: no tener seguro médico para tratar su enfermedad

y su miedo a perder a su prometido. No obstante, como este artículo examina,

Cancer Vixen refleja que la medicina gráfica, como nuevo género narrativo, mitiga

el antagonismo entre médicos y pacientes, a la vez que ayuda a que profesionales

sanitarios y expertas/os en literatura empaticen con las historias personales de las

enfermas de cáncer de mama más allá de encuentros clínicos y hospitalarios.

Palabras clave: cáncer de mama, diarios, medicina gráfica, paciente, profesional

sanitario.

1. Autopathographies on Breast Cancer

Breast cancer forms in the cells of the breasts and, according to the Mayo Clinic,

it is the second most common cancer diagnosed in women in the United States.

Breast cancer patients face traumatic, invasive surgical procedures, such as

lumpectomy, mastectomy and breast reconstruction, often in combination with

equally painful hormone therapies, chemotherapy and radiotherapy. Historically,

cancer has been enveloped in a fog of secrecy, fear and stigma that renders

individuals with the disease socially invisible and their post-surgery, post-treatment

anatomies weak and ravaged. As Susan Sontag notes, because cancer has been felt

to be a “morally, if not literally, contagious” disease, many cancer patients have

been shunned by relatives and friends as if they had an infection (1978: 3). In

recent times, social awareness and research funding have helped to advance the

diagnosis and treatment of breast cancer to the point that, today, deaths associated

with this illness have declined thanks to enhanced understanding of the disease and

an individualized treatment regimen for each patient’s recovery. Caring for the

individual experiences of women with cancer and showing empathy for their

physical pain and psychological damage during their illness are vital battles to

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eliminate the fog around cancer. During second-wave feminism, women’s political

activism along with literature have contributed to defeating breast cancer both

medically and socially. Adrienne Rich posits that, in the second half of the twentieth

century, a vigorous feminist movement advocating for medicine to support female

needs, has defied the medical industry and healthcare systems, which have been

arrogant and indifferent to women (1986: x). Female patients have been essential

to this health feminism in their refusal to submit to medical authority —often

male— and have reclaimed their rights to be listened to by health professionals and

to tell their own stories about their ill —or pathologized— bodies and minds. As

Anne Boyer states, “disease is never neutral. Treatment never not ideological.

Mortality never without its politics” (2019: 123), so women’s life-writings have

joined the public debate around female health rights and survival. Notably, two

paradigmatic texts advocating for greater empathy and better care by the medical

profession in the management of women’s illnesses are The Bell Jar (1963) by

Sylvia Plath, related to mental health and psychiatry, and The Cancer Journals

(1980) by Audre Lorde, for breast cancer and oncology.

Edmund Pellegrino, a pioneer of modern medical ethics, contends that “medicine

is the most humane of sciences, the most scientific of the humanities” (2011:

313). The interdisciplinary field of medical humanities explores human health and

disease through the methods and materials of the creative arts and humanities,

including literature. This discipline envisages improving healthcare practice by

influencing its practitioners to both refine and complexify their judgments in

clinical situations based on a deep, complex understanding of illness, suffering and

personhood (Shapiro et al. 2009: 192-193). Medical humanities offers health

professionals knowledge and sensitivity about the patient’s experience of illness,

her circumstances and surroundings and her emotional spectrum —from strength,

courage and optimism to vulnerability, panic and defeatism— which have been

traditionally ignored by the education and routine work of health practitioners;

yet, they enrich the quality of medical care and foster mutual understanding in

doctor-patient relationships.

Medical humanities also enlightens literary scholars to better examine the genre of

autopathography, which Anne Hawkins defines as “a form of autobiography […]

that describes personal experiences of illness, treatment, and sometimes death”

(1998: 1). To explain the artistic boom in autopathography since the second half

of the twentieth century, Hawkins argues that an autopathography is a “modern

adventure story” when “life becomes filled with risk and danger as the ill person is

transported out of the familiar everyday world into the realm of the body that no

longer functions” (1). This type of illness narratives1 also becomes “the logical

counterpart to the medical history written by the physician” because it describes

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how the experience of being sick and the treatment of illness are understood by its

patient, who is its author (12). Beyond the impersonal, objective knowledge of a

biomedical condition on the part of health professionals, the subjective first-person

account of being ill is a literary form that gives voice to typically silenced individuals

—the patients— and describes how their lives are conditioned by disease. For

Thomas Couser, an autopathography becomes a cathartic act of scriptotherapy “by

heightening one’s awareness of one’s mortality, threatening one’s sense of identity,

and disrupting the apparent plot of one’s life” (1997: 5); so to say, the act of

writing about being ill facilitates the patient’s emotional recovery. Additionally, an

autopathography denounces social constructions of the sick body as evil,

dangerous, shameful or ugly, while becoming a personal counternarrative of the

patient’s fight against their marginalization and dehumanization in clinical

interactions and elsewhere. Illness involves the transient or enduring alteration not

only of the physical self, but also of the inner self. Virginia Woolf emphasizes the

tremendous spiritual change that illness brings to its sufferer, who feels “the waters

of annihilation” (1926: 32). An autopathography thus expresses emotional pain,

fear and anxiety or how harrowing it is to be seriously ill and, even, to face death.

Yet, as Theresa MacPhail states, this form of illness narrative is “a method for

coming to terms with the myriad effects, both positive and negative, on our worlds

of any crisis, chronic illness, or contagious disease” (2014: 5). Indeed, an

autopathography also illustrates an individual’s ability to transform the ordeal of

being sick, making it into an empowering act leading to personal growth,

knowledge about the world, finding meaning in life and even laughing at adversity.

In the case of cancer, Federica Frediani contends that this disease suddenly and

brutally drives patients to a marginal space, where their bodies are exposed to

violent therapies —ultimately to loss and even to death— so they feel separated

from their former selves, and writing their stories becomes a tool with which to

reclaim agency, deal with grief, reconnect with their former identities and, in the

process, acquire a new one (2017: 254). Accordingly, as an autopathography, The

Cancer Journals shares Lorde’s fear of dying and mourning of her amputated right

breast. Yet, she accepts her new post-mastectomy physical self and defends any

woman’s right and duty to speak of her illness and to make her own decisions

about her body. Sontag argues that metaphors to describe cancer and its treatments

usually come from the language of warfare and military terminology (1978: 4).

Symbolically, cancer cells are enemies that invade and massacre the cancer patient’s

body and are counterattacked by oncologists. In The Cancer Journals, Lorde

becomes a warrior who narrates her early battles during her fourteen-year personal

war against breast cancer. She also aims the artillery of her feminist criticism to

target the often-insensitive medical profession, the cold hospital institution and

the profit-driven beauty business of replacement breasts. Lorde sees enemies both

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inside her own body —the cancer cells— and outside her body —healthcare

providers. Hence, how can the rage in The Cancer Journals help (future) health

professionals to advance their expertise and treatment of patients afflicted with this

illness? If we trust Virginia Woolf’s harsh analysis of Charlotte Brontë’s Jane Eyre,

the use of anger discredits a writer and ruins her literature. The purpose of this

essay is twofold. On the one hand, it discusses key angry elements from The Cancer

Journals, which can be, indeed, instructive for health practitioners, and reflects the

beneficial use of humor in comics belonging to the new literary genre known as

graphic medicine, like Cancer Vixen (2006) by Marisa Acocella Marchetto (1962),

to enhance doctor-patient communication. On the other hand, focusing on the

field of literary studies, this article highlights the power of autopathography as a

consolidated narrative form, to become an effective therapy for authors and

intended readers to navigate sickness and its mental wounds, while gaining an in-

depth understanding of the subjective experience of illness that counterbalances

the authority of physicians and healthcare systems in the management of breast

cancer.

2. The Patient’s Anger: Audre Lorde

Cancer patients may construct their own narratives as subjective experiences of

illness beyond the patient-doctor encounter, their medical history and the scientific

management of their symptoms (Karpf 2013: 179). In agreement with this writing

choice, Lorde’s The Cancer Journals does not revolve around breast cancer itself,

but around what it feels like being a woman with this illness: her mental and

physical pain, despair and fear of dying. Lorde’s autopathography, stressing her

own emotions and sensations, complements objective knowledge about breast

cancer that health professionals must acquire and employ at work on a daily basis.

Iris Young argues that, in our culture, the woman feels and is, indeed, judged and

evaluated according to the size and contours of her breasts, both as visible signifiers

of her womanliness, and as fetishes, thus blurring the lines between sexuality and

motherhood and becoming objects of sexual desire (2005: 76-77). Accordingly,

non-medical readers of Lorde’s autopathography also observe that having breasts

is not only a biological fact about the female anatomy, but also a worry, or even an

obsession, in women’s lives. Breasts become some kind of discourse for patients to

be accepted and approved in social and sexual contexts. Mastectomy is surgery to

remove all breast tissue from a breast to treat or prevent breast cancer, including

breast skin and nipple. It is a routine operation for doctors; yet, for women, this

procedure involves both a physical loss and the mental mourning of that loss. The

surgery to restore the shape of an amputated breast is called breast reconstruction

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and may be undertaken at the same time as a mastectomy or in a second operation

later. In The Cancer Journals, Lorde confesses that she is against prostheses as “a

norm for post-mastectomy women” (2020: 56) and against breast reconstruction,

although she admits that other women are entitled not to share her views and

choices about her ill body. Lorde decides never to hide the fact that she has a

missing breast as she reflects in her autopathography. Ten days after her mastectomy,

she remembers visiting her doctor for the first time without a prosthesis —a “wad

of lambswool pressed into a pale pink breast-shaped pad” (34)— and being

confronted by a nurse, who tells Lorde “you will feel so much better with it on”

(52) and who reprimands her for not wearing one, because it was “bad for the

morale of the office” (52). The text reveals that, for this medical staff, Lorde’s

choice represents a defeat for other cancer sufferers. The nurse does not care for

the patient’s own morale and denies her space to mourn the painful change in her

body (Karpf 2013: 187). Lorde confesses being speechless during that encounter,

and that is why she makes her own diagnosis in The Cancer Journals: the patient’s

silence about her health rights and feelings is as harmful as cancer itself, so ill

people must find their own voices to defend themselves against verbal assaults,

while healthcare workers must avoid inconsiderate remarks.

Divided into three parts, The Cancer Journals were written between 1977 and

1979 when, like Marchetto, Lorde was in her forties. In its second part —“Breast

Cancer: A Black Lesbian Feminist Experience”— she explains her experience with

mastectomy and feeling discriminated against as a person with breast cancer. This

section alternates among Lorde’s recollections, recording transcriptions and the

reprint of short journal entries written by her in the hospital. The use of tape

recordings during her stay in the medical institution, which she replays at home at

the time of writing The Cancer Journals, was the way in which Lorde captured

what she could not bring herself to write in her journal because she was weak, tired

and in pain. The author claims that healthcare systems and professionals do not

seem to care about the emotional problems of cancer patients who endure invasive

surgery. Alfred Hornung states that, in The Cancer Journals, the hospital

institution, including its layout and organization, extinguishes all feelings and

“reduces human beings to the status of what the word patient literally means: a

non-active persona acted upon” (2022: 133), just as Lorde recalls: “the very bland

whiteness of the hospital, which I railed against and hate […] a blank environment

within whose undifferentiated and undemanding and infantilizing walls I could

continue to be emotionally vacant —psychic mush— without being required by

myself or anyone to be anything else” (2020: 38-39). Besides, Lorde is invaded by

fear: “There is the horror of those flashing lights passing over my face, and the

clanging of disemboweled noises that have no context nor relationship to me

except to assault me” (28). The repetitive start of each sentence with “I remember”

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shows the depersonalization or dehumanization felt by Lorde as a post-mastectomy

patient in hospital: “I remember screaming and cursing with pain in the recovery

room, and I remember a disgusted nurse giving me a shot. I remember a voice

telling me to be quiet because there were sick people here, and my saying, ‘well, I

have a right, because I’m sick too’” (28-29). Although doctors partly rely on

information provided by their patients, they assume all responsibility for diagnosis,

prognosis and therapy, while patients submit to their doctors’ authority for the

decision-making in the management of their illnesses (Lupton 2012: 112). To

function effectively, hospital life also involves routines and regulations which

nurses and other healthcare workers impose on patients. Lorde depicts a side of

medicine and healthcare that training in these fields discount: the incongruity

between what the patient considers to be her life’s great crisis, characterized by

powerlessness and her subjugation to forces outside her control, and the fact that

such crises, for healthcare providers, seem a part of the everyday routine of their

professions (Schleifer and Vannatta 2019: 96). Lorde also feels that she is being

ignored and damaged by health professionals, who disregard her emotional needs,

while they control and monitor her ill body.

Beyond being an autobiographical testimony of illness, The Cancer Journals also

becomes literary when Lorde asserts her desire to survive, not to die; to be a

warrior, not a victim. In her journal entry from September 21, 1978, she wonders

how in previous centuries, the women warriors of Dahomey —the only known

all-female army in history— coped with losing one of their breasts when they

were only girls. These female soldiers from the African kingdom of Dahomey —

today’s Benin— were known for the fierceness and courage in combat to protect

their king, so the Europeans who first encountered them, called them Amazons.

In The Cancer Journals, Lorde employs the term Amazon to describe the

Dahomey women warriors because, according to Greek mythology, Amazons

were excellent horse riders who cut or burned off their right breasts to have

better bow control and become more effective archers. Amazons are also a

feminist myth of powerful, independent warriors who fought in wars against

male-dominated societies and lived freely in all-female communities, and they are

frequently found as characters in breast cancer memoirs. Although Greek

Amazons and the Dahomey warriors were not part of the same civilization, Lorde

fuses them and wonders how they must have felt when having their breast cut off.

She does not describe her own mastectomy to her readers but compares her own

sacrifice —the amputation of her right breast to escape death— with the sacrifice

of Amazons and the Dahomey warriors —the amputation of their right breasts to

become better fighters. But more importantly, Lorde identifies herself with these

mythical and historical women to embrace her new identity as a one-breasted

survivor. In her analysis of the language of warfare, Robina Khalid argues that

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during the process of her recovery, Lorde imagines herself to be a warrior as a

defense mechanism against those who would make her feel inadequate after the

surgery (2008: 701), including health professionals. Instead of having swords or

bows with arrows, Lorde has words as weapons to help herself and other breast

cancer sufferers to heal and, like Amazons and the Dahomey warriors, she

cherishes living in a community of women, who offer her love and support in her

war against cancer.

In The Beauty Myth, concerned with society’s unrealistic standards of flawless

female physical beauty, Naomi Wolf argues that women delay mammograms for

fear of losing a breast and becoming “only half a woman” and, although implants

make cancer detection more difficult, women increasingly choose to undergo

breast surgery for purposes of enhanced sexual desirability (1991: 229, 243). A

leg prosthesis is useful because it helps a person to walk, but Lorde believes that

breast prostheses, or “false breasts” (2020: 56), are cosmetic devices placed not

for well-being or health reasons, but instead are designed “for appearance only”

(56). This intensifies the belief that, in our culture, being a woman means having

breasts, while having perfect, prominent and symmetrical breasts means being a

more worthy female. Contrary to these rules, Lorde embraces her own deviance

from biology and the beauty canon after mastectomy: “Prosthesis offers the

empty comfort of ‘Nobody will know the difference’. But it is that very difference

which I wish to affirm, because I have lived it, and survived it, and wish to share

that strength with other women” (54). Lorde reconceives her own anatomy by

explaining what her breast means to her: it gives her pleasure, but not apart from

the rest of her body (Alexander 1994: 701). Although she mourns her beautiful

right breast which was removed, she believes that she must reconcile herself with

her forced loss, instead of concealing this physical loss by means of a prosthesis:

“Either I would love my body one-breasted now, or remain forever alien to

myself” (Lorde 2020: 37). She also rejects existing gender stereotypes in society

that support that post-mastectomy female patients like herself are asexual and

unattractive, when she insists that “a woman can be beautiful and one-breasted”

(57). Indeed, Lorde places herself “in the vanguard of a new fashion” (58), as

the first one who designed clothes and jewelry to favor “asymmetrical patterns”

(58), and intended to be worn by one-breasted women like herself. Readers of

The Cancer Journals, both healthcare workers and those outside of the medical

field, can admire Lorde’s fierce determination as a post-mastectomy warrior,

while realizing that breast cancer patients not only endure a life-threatening

illness, but also life-lasting social and sexual pressures and expectations to

maintain female beauty standards about their breasts, compulsorily viewed in

plural.

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Lorde also condemns the process by which a prosthesis trivializes and ignores

women’s own perceptions of themselves, particularly in the case of African

American female patients like herself. This is illustrated by the episode of a

volunteer from the US association Reach for Recovery who visits her after her

mastectomy. While this white person praises the advantages of prostheses, Lorde

“look[s] away, thinking, ‘I wonder if there are any black lesbian feminists in Reach

for Recovery?’ […] I needed to talk with women who shared at least some of my

major concerns and beliefs and visions, who shared at least some of my language.

And this lady, admirable though she might be, did not” (2020: 35). Lorde explains

that the pink prosthesis “was the wrong color, and looked grotesquely pale through

the cloth of my bra” (36). By denouncing how her own racial difference is

discounted by this pale-colored prosthesis manufactured for white women, she

emphasizes how illness —like being Black, a lesbian and a mother— is not

experienced in a uniform way by all women: she is not like others; she does not

want to comply with the social norm of having, or pretending to have, two breasts.

Lorde appears to represent the racist cliché of the Angry Black Woman (ABW)

which permeates US culture. As Melissa Harris-Perry states, Black women’s

passion and righteous indignation are often misread as irrational anger, so this

image is used to silence and shame them if they chal lenge social inequalities,

complain about their circumstances or demand fair treatment (in West 2018: 149).

Yet, Lorde transcends the social punishment inherent to the ABW stereotype and

exhibits the literary use of loud anger in her autopathography to denounce white

privilege and the invisibility of Black patients in the (medical) treatment of breast

cancer patients.

The Cancer Journals also discusses the profit-oriented medical industry of breast

reconstruction. Lorde rejects the aesthetic operation of silicone gel implants

inserted by plastic surgeons, as well as the preventive removal of her heathy left

breast. She views the demand for a normal body, on which the choices of prosthesis

and breast reconstruction are based, as “an index of this society’s attitudes toward

women in general as decoration and externally defined sex object” (2020: 53).

Contrary to this, Lorde asks that health workers, from doctors to volunteers in

cancer associations, respect her decision, which strengthens the educational

dimension of her autopathography for all types of readers. Mastectomy was

mandatory to save her life. Conversely, wearing a prosthesis and breast

reconstruction do not obey medical, but social impositions of feminine beauty and

homogeneity.

The Cancer Journals gives visibility and strength to its author and to her female

readers as breast cancer patients to define and empower their post-mastectomy

selves. Any lethal illness is a life crisis, but also has the potential to change one’s

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life. Unlike other women choosing to ignore the pain and fear of cancer, Lorde

seeks strength at the heart of her own cancer experience: she uses her pain and fear

to better understand that the high risk of dying is a source of power. Death must

be integrated into life and cancer enables Lorde to embrace her new one-breasted

body, to learn to love life, and enjoy being alive. Beyond the fact that her

autopathography is the best therapy of self-healing, it is equally important for

Lorde to admit, thanks to her cancer ordeal, that health is a political issue: “If we

are to translate the silence surrounding breast cancer into language and action

against this scourge, then the first step is that women with mastectomies must

become visible to each other” (Lorde 2020: 54). Being a voiceless patient means

powerlessness, particularly in the case of female Black patients. Meanwhile, writing

about illness means becoming powerful because, as Hornung notes, by extending

her text into the reality of her readers, Lorde builds a “community of like-minded

people” sharing a common experience (2022: 133). Arthur Frank claims that one

type of illness narrative is the “quest story”, in which the ill person accepts their

illness and believes that “something is to be gained” through the experience of

being sick (1995: 115-116). The Cancer Journal is, indeed, the story of a quest in

which Lorde embraces her own cancer to make a meaningful contribution to the

world: patient advocacy. In other words, her autopathography seeks to gain rights

for its intended addressees —other breast cancer warriors— and to win the war

against the social stigmatization and the medical dehumanization that women may

endure on their journey toward survival or death. Identifying these two pathological

conditions associated with breast cancer becomes Lorde’s proposal to educate any

reader of her quest story.

3. The Patient’s Humor: Marisa Marchetto

More than twenty years after Lorde published her autopathography, the Italian

American cartoonist Marisa Acocella Marchetto writes Cancer Vixen, whose

artistic gun is not loaded with Lorde’s anger, but with humor to narrate her

eleven-month story with breast cancer, from diagnosis until cure. Nancy Walker

identifies essential characteristics of women writers’ humor in the United States:

they write about what they know best and concerns them most; their humor is less

aggressive and hostile than that of men; and their jokes can capture the incongruity

between promise and reality to send feminist messages toward gender equality

(1998: 32). However, race is not accounted for in Walker’s description of humor,

so whiteness is presented as a universal feature, like Lorde’s pale-colored prosthesis

manufactured for white women. Marchetto’s graphic novel is consistent with these

traits of US female humor: she writes about herself; she does not attack but,

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instead, nurtures friendly ties with health professionals; and she guides unrealistic

women, who may resist learning more about breast cancer, doing self-exams and

having mammograms after reaching the age of forty. However, Cancer Vixen also

epitomizes the illuminating power of graphic medicine to serve both healthcare

and the literary study of illness narratives. Since its coinage in 2007 by the comic-

doctor Ian Williams, graphic medicine has entered medical humanities as an

umbrella term for comics and graphic novels on being sick. In 2015, comic-nurse

M.K. Czerwiec and her collaborators published The Graphic Medicine Manifesto,

which defines graphic medicine as “the intersection of the medium of comics and

the discourse of health care” to train health professionals, and as “an emerging

area of interdisciplinary academic study” (2015: 1). This type of comic, exemplified

by Cancer Vixen, becomes a valuable text for both readers employed in healthcare

and scholars on illness narratives to better understand their authors as patients and

the power of literature toward (self-)healing, while enhancing quality care and

communication in doctor-patient encounters. Physicians may successfully excise a

cancerous tumor and, later, find its best clinical treatment, but they also need

instruments to stop the cancer sufferers’ emotional bleeding in the process of

eliminating illness.

Traditionally, humor has been viewed as a form of entertainment, not as serious

writing to be immortalized by the literary canon, and the same can be said for

comics, which usually employ humor. Traditionally, writing has never been a

decent career for women, as in the advice given to US wisecracker Dorothy Parker

by her grandfather, which she comically expresses in a poem: “My dear,/

Remember what I tell you when you’re choosing a career: […] Rob your neighbors’

houses in the dark midnight;/ but think of your families, and please don’t write”

(2010: 309). Traditionally, humor is unsuitable, vulgar and offensive when

narrating a serious, painful and dangerous illness like cancer. Contrary to all these

traditions, Marchetto —a female illustrator working for the magazines Glamour

and The New Yorker— uses satire and comedy to laugh at her illness and at herself

as a patient toward purposes of survival and self-healing, because, as The Graphic

Medicine Manifesto states, “comics have often been associated with cultural

changes and are ideal for exploring taboo or forbidden areas of illness and

healthcare” (Czerwiec et al. 2015: 3). Cancer Vixen does.

Marchetto’s graphic novel recounts her cancer experience in chronological order,

including the continuation of her professional career as a cartoonist and her

romance and ultimate marriage to the famous restaurateur Sylvano. Breast cancer

is, therefore, not the only narrative event in Marchetto’s life during the eleven

months of her illness. In Cancer Vixen she uses parody and clowning in her self-

portrait as a patient, as if she personified a happy-go-lucky fictional female character

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snatched from the US television show Sex and the City: “a shoe-crazy, lipstick-

obsessed, wine-swilling, pasta-slurping, fashion-fanatic, single-forever, about-to-

get-married big city-girl cartoonist […] with a fabulous life” (2006: 1), when she

“finds… a lump in her breast?!?” (1). Text and images reflect that urbanite Marisa

loves being a socialite in New York’s vanity fair: haute-couture clothes, high heels,

fancy cars and restaurants, expensive getaways to Europe, glamorous galas before,

during and after her illness, because her daily existence can be fabulous —if she

wants it to— even while having a tumor in her breast. Cancer might kill her, but it

cannot define her or rule all her days and nights. Marisa is not what a scholar in

literary studies expects to find in a patient with a life-threatening illness: neither

the helpless victim to be pitied nor the furious warrior, like Lorde, to be admired,

because there is no prototype for breast cancer sufferers. For Arthur Frank, another

type of illness story is the “restitution narrative”, whose plot is, “Yesterday I was

healthy, today I’m sick but tomorrow I’ll be healthy again” which reflects a natural

desire to get well (1995: 77-78). Cancer Vixen is a restitution narrative in which

Marisa remains as frivolous, vain and funny as she used to be, while being serious

about fighting the war against illness, recovering her physical and mental health

from cancer, and surviving.

Her graphic novel begins when Marisa discovers a lump in her left breast, goes to

Dr. Mills’s clinic, and a biopsy confirms the diagnosis of cancer, so she must

undergo a lumpectomy. This breast-conserving surgery removes cancer or other

abnormal tissue from the breast, including a small amount of healthy tissue that

surrounds it to ensure that all the abnormal tissue is removed; thus, not all the

breast tissue. Dorothy Judd lists some states of mind which a life-threatening

illness may provoke in people with disease can experience, like uncertainty,

nameless dread, loneliness, falling forever, catastrophic change, guilt, mourning,

or the need to make reparations (2013: 27-28). When Marisa finds out that she

has breast cancer and must endure a surgical procedure, some panels in the same

page of Cancer Vixen reflect these feelings: “The Electrolux of the universe sucked

me into a black hole. I was alone, afraid. Frozen in time for an eternity in a vast

expanse of nothingness, surrounded by dark matter… wishing I could just go back

to worrying about my stupid, self-absorbed, self-esteem, weight, bad-skin, bad

hair issues that had obsessed me my whole life…” (Marchetto 2006: 9). Here,

words capture her distress; the drawing parodies her fall into darkness, while color

plays a vital narrative role in this example of graphic medicine, because it adds

meaning to text and sketches, notably, her emotions. Thanks to the visual presence

of red in her shoes and black in her surroundings, the reader observes the intensity

of the cancer patient’s anxiety at having no future and the fear of dying soon. Yet,

in her graphic novel, she keeps her sense of self during her descent into the hell of

coping with illness: she still wears her trademark high heels.

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Before enduring a lumpectomy, Marisa’s text and images show that, suddenly,

three interrelated problems coexist in her daily routine: breast cancer, no insurance

to pay for this procedure to eliminate cancer, and no assurance that her fiancé

Sylvano will ever marry her as a cancer patient. She should focus all her energy on

winning the war against her illness, but she cannot. Indeed, she is forced to devote

two thirds of her emotional resources to two other inescapable endeavors: she

must tell Sylvano the bad news and later, prove to him that she is not so sick that

she cannot still enjoy the dolce vita that his money and high social status afford her,

as well as manage to pay the bills of about USD 200,000 for the lumpectomy and

subsequent medical treatment. In the early twenty first century, US healthcare was

ruled by the Health Maintenance Organization (HMO) —a group of insurance

providers, which offered insurance coverage for a monthly or annual fee that not

all Americans could afford or would remember to pay. David Morris explains that

this system negotiated contracts with hospitals and health professionals, while

limiting doctors’ autonomy about treatment, because decision-making often

rested with cost-conscious bureaucrats, and an HMO may withhold access to care

from some patients, which undermined their health and eroded their trust in the

medical profession. Morris further states that “an illness does not count as illness

unless HMO certifies it” (2007: 13).

Cancer Vixen is a collage combining various visual and textual elements, including

Marisa’s own medical reports and statistics from the National Breast Cancer

Foundation to add individual veracity to what, for her, is a problematic situation

in US society and legislation: “Fact: women without insurance have a 49% greater

risk of dying from breast cancer. And when it’s needed the most, that’s when it’s

the hardest to get” (Marchetto 2006: 94). Health workers and scholars in literary

studies may overlook the added anxiety when, unlike in Europe, cancer sufferers

were not protected by a tax-funded, government-subsidized healthcare system in

the United States but sometimes were, instead, at the mercy of the profit-driven

business of care and cure. Beyond visualizing Marisa’s agony because she has no

health insurance, Cancer Vixen suggests that US oncologists violate the Hippocratic

Oath when they fail to uphold the ethical standard of non-maleficence: their forced

inaction to treat the uninsured cancer patient means harming that patient. Not

only being poor but also oversight may be the reason why some US women have

no health insurance with which to cover the expenses of surgery and later therapies,

because as Cancer Vixen reflects, it is human to think that others —never us— will

endure a life-threatening illness. Marchetto’s graphic work illustrates how she

recalls that her coverage had just lapsed right when she most needed it: when she

was diagnosed with a tumor in her breast. Then, profit-driven insurance companies

reject her. Her economic problem renders her invisible vis-à-vis health professionals

and adds distress to her life, which complicates her efforts to heal, and can even

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jeopardize her chances to receive the best cancer treatment. Indeed, Cancer Vixen

exposes the inequalities of healthcare systems because it is sometimes money —not

a dangerous illness— that decides whether one lives or dies. Marisa’s humor

pictures her unfounded fear: being rejected by her wealthy fiancé because she

receives her cancer diagnosis only three weeks before her wedding and dreads that

Sylvano will not marry an ill bride. However, he still loves her with cancer and adds

her name —as his wife— to his medical insurance so, unlike less fortunate women,

Marisa’s success story means that she has the romantic economic means to survive

and live happily ever after, like in fairy tales.

Whereas money and love are narratives that eventually find a happy ending, Cancer

Vixen must also necessarily address illness itself and captures how medical speech

frequently chooses euphemisms that are not useful for patients. Before surgery,

Marisa’s mother asks Dr. Mills if her daughter should stay at home with her after

lumpectomy, and he says: “Even though she probably won’t stay overnight… This

is a major procedure” (Marchetto 2006: 115), which Marisa translates as “There

will be pain” (115). She does not care about spending the night in hospital, alone

in her flat or being looked after by her mother, because all that matters to her, what

frightens any cancer sufferer, is excruciating pain. Yet, this is not always information

that a doctor eagerly discloses. A later sequence of panels in The Cancer Vixen

shows lumpectomy from the patient’s eyes on the operating table. First, the

practitioner’s words before administering anaesthesia to Marisa: “OK, we’re going

to excise the tumor and…” (119); then, black color to show that she “was out”

(119); and finally, waking up after this procedure and hearing him again say “The

operation was a success, and it looks like the margins were clear” (119). Sketching

reflects the practitioner’s blurred image, which is what Marisa —still dizzy— sees

when she recovers her consciousness. In the last sketch, she educates non-physician

readers about lumpectomy: a peach symbolizes the breast tissue extracted during

the surgery and inside, its pit was the cancer that was excised. Some time after, Dr.

Mills informs Marisa at his office:

You had early breast cancer. The tumor is completely removed. It was 1.3 centimetres.

Chemotherapy and hormone therapy are systemic treatments. They treat the whole

body. They lessen the risk of the disease spreading somewhere else. Surgery and

radiation are local treatments. Radiation treatment to the breast significantly reduces

the risk of recurrence. Radiation is given because there could be cells in transit that

have been undetected. (123)

Panels from Cancer Vixen evince that physicians sometimes communicate poorly

with their patients. Dr. Mills assumes that Marisa is familiar with technical details

of cancer treatment and does not realize that, overwhelmed by the fact that her

ordeal has not yet ended, she is unable to absorb all the information that he

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transmits to her. Furthermore, post-surgery patients have more pressing

preoccupations, which are not necessarily addressed by doctors, like in Marisa’s

case: “How long are treatments? How often are treatments? How many treatments

will I need? Will I be tired? What kind of exercise should I do? Can I keep

working? Does each treatment get progressively worse? Will I throw up? Can I

travel? How nauseous will I be? When will this ever end?” (2006: 144). Yet, this

is not textually reflected as a conventional list of concerns. Graphic medicine

offers readers from the healthcare field and beyond additional non-verbal

information. Thanks to the use of a larger typeface for some of Marisa’s questions,

it is evident that she has three priorities: to know how exhausted she will be, if

each treatment will gradually intensify her pain, and if there is light at the end of

the tunnel of cancer.

Chemotherapy is a drug treatment that uses powerful chemicals to kill cancer cells

that can easily and quickly multiply in the patient’s body, although it carries risks

of side effects and is painful. Susannah Mintz contends that, although it has

become “a truism that pain cannot be described, that it defies representation in

language”, pain can be uttered in literature (2013: 4). Cancer Vixen reflects that,

after surgery, invasive chemo must treat Marisa’s cancer, and visualizes the most

frightening artifact during its sessions: the needles, which were initially shown

when a biopsy removed breast tissue to diagnose cancer. But, more importantly,

Marchetto’s synergy between comical sketches and serious language in her work

explains pain to health professionals and scholars in literary studies and what she

feels after chemotherapy: “Imagine being injected by a truckload of wet cement.

Imagine that truckload… hardening… in your entire body, immobilizing you with

extreme muscle and bone aches” (Marchetto 2006: 164). Pictures and text

eloquently describe the chemo aftermath: its intrusion into her ordinary life and its

heavy burden of suffering and paralysis because, for days between sessions, Marisa

is prostrate in bed.

In the United States, some medical institutions today work with graphic artists to

spread information about healthcare issues and treatments among the public,

while graphic novels appear on syllabi in medical humanities courses and medical

schools encourage students to read comics about illness to gain empathy and

insights into what their patients may be experiencing (La Cour and Poletti 2021:

2). Cancer Vixen prioritizes the interactions between the patient and healthcare

workers. As graphic medicine, it has the potential to educate students, because

they can see themselves as future doctors in the mirror of comic panels and observe

details about the practicalities of cancer treatment that typically go unnoticed but

can be valuable information when following-up their patients; like the discomfort

that cancer sufferers feel but do not dare to confess to doctors. As a taboo breaker,

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Cancer Vixen is useful for both the medical profession and scholars in literary

studies. Marisa is embarrassed in front of Dr. Paula due to her flatulence’s bad

smell: “Chemo farts. Nobody, I mean nobody, told me about them” (Marchetto

2006: 161). Meanwhile, she is a slave to society’s beauty standards of thinness and

abundant hair. Due to chemotherapy, she suffers because she is putting on weight.

Text and images show that, for Christmas, she offers a gift to one of her doctors:

“Mary Ann, we brought you some cookies” (181), which this practitioner accepts:

‘Oh, I’m on a diet. But I’ll take them anyway” (181). Marisa not only thanks her

doctor and takes the liberty of calling her by her first name as they have become

friends, but she also uses humor to symbolically take revenge against Mary Ann,

who is ordering chemo sessions for the author and is as obsessed with gaining

weight, as is Marisa herself. The greatest fear in cancer is death, while the greatest

fear in chemotherapy is hair loss, which scares most women. Marisa makes a parody

of her frivolous pre-cancer self as her tactic to confront the terror of not looking

attractive for herself and for others: “All those complaints about bad hair days… I

just should have been thankful I had it” (124). Between being comical and serious,

she shares her worries with Dr. Klein: “Let me be really straight. My husband owns

a restaurant where the most beautiful women go and I can’t look like crap!... and

I will kill myself if I lose my hair” (132). Indeed, Marisa has already been a victim

of the cancer stigma when a girl openly flirted with Sylvano in front of her, gave

him her card, and told him: “I’m not sick… call me if you want a healthy

relationship” (99). Because of her illness’ early stage, Marisa can “enjoy […]

chemo light. Light chemo…” (132), which comically for her “sounds like a soft

drink…” (132). Dr. Klein not only listens to her patient and writes down Marisa’s

farcical threat of suicide in her medical history, but also angrily warns her: “There’s

nothing soft about it… chemo light is still chemo” […] I would never let you risk

your life to save your hair” (132). Therefore, both medical competence and

sympathy are found in Dr. Klein’s praxis, while readers of Cancer Vixen who are

not part of the healthcare industry see that Marisa succeeds in navigating through

the threatening waters of light chemo because she obeys the social expectation of

feminine beauty: her hair.

Part of a physician’s expertise in managing disease and its sequalae is to know and

understand a patient’s story, particularly when she is not in the doctor’s office

(Myers and Goldenberg 2018: 158). Sometimes cancer diagnosis is accompanied

by a bad prognosis beyond illness itself. During chemo sessions, Marisa learns that

it is impossible for her to become a biological mother. In a panel, after informing

her about the onset of her early menopause due to her treatment, her doctor asks

her: “Are you OK? You look upset” (Marchetto 2006: 150). Marisa replies: “Well,

I was just given some pretty terrible news considering I’m 43 and it’s already late

for me to have children” (150). This is a typical doctor-patient conversation, but

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to foster empathy, healthcare and lay readers of Cancer Vixen also penetrate

Marisa’s realm of emotions after she discovers that she will remain childless: cancer

invalidates the narrative of motherhood in the future. Outside the clinic, she

imagines a baby boy in the sky, who says, “Hey Mom! Up here! Your son wanted

to say goodbye. My time’s up. I’m not happening in this lifetime” (150), to reveal

how she tries to assimilate the news she received from her doctor, and to mourn

her maternal loss.

The graphic novel reproduces other routine episodes of check-ups during cancer

treatment. Dr. Klein —now called Paula— asks Marisa whether or not she is

experiencing chemo side effects, like nausea, hot flashes, night sweats, fatigue and

diarrhea. When she confirms all of them, this doctor adds empathy to her clinical

practice by asking her patient, “How’s everything else?” (Marchetto 2006: 189),

which implies interest in non-health issues affecting the life of Marisa, who replies:

“I got no complaints” (189). As a patient, she is not a troublemaker and instead,

maintains a positive attitude, which is both vital to recover her health and not to

alienate her doctors. She does not blame physicians for her physical pain,

discomfort, early menopause and infertility. Nevertheless, Cancer Vixen does not

incorporate any racist experiences because, as a white patient, racism is absent from

Marchetto’s personal account of illness, as opposed to the medical hostility and

social invisibility suffered by a Black woman, which Lorde narrates in her

autopathograhy. When Marisa successfully finishes her treatment and is cancer-

free, friendly goodbyes at the clinic prove that she established good relationships

with health workers. Yet, Cancer Vixen also reflects that every time she sees the

white coat of a doctor who calls her name during a post-cancer check-up, “there

will always be a second where I lose my breath” (208), implying that Marisa is

always afraid of visiting a clinic and receiving bad news about cancer recurrence,

even if her doctor is only going to say, “you can change out of your gown” (208).

Thus, readers of Marchetto’s work from the healthcare field can learn to be careful

with patients after recovery from their disease, whereas her readers in literary

studies observe emotional residue of post-cancer fear, also omnipresent in Lorde’s

journals.

4. Life Lessons in Cancer Narratives

Marisa becomes a cancer vixen, or a victor, because she fails to allow illness to deflate

her spirit, and the last page of her graphic novel, showing her driving with her

husband in his Maserati on their one-year wedding anniversary, sends the final

message of her success (Chute 2017: 416). Some women survive cancer, like

Marchetto, while others, like Lorde, die. However, her autopathography from

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1980, including her furious critique of the medical profession, has paved the way

for later generations of breast cancer sufferers as authors like Marchetto. First,

Lorde empowered these women to raise social awareness about their illness;

second, she prompted them to elicit both self-healing through the act of

writing autopathographies and healing through the act of reading them by

other female patients; and third, Lorde urged them to fight to improve patient-

doctor relationships. Narratives like The Cancer Journals and Cancer Vixen

have the power to enhance both healthcare providers’ clinical practice and

students’ education. Lay readers of Lorde’s autopathography enjoy her literary

audacity when comparing herself to the mythical Amazons and the historical

Dahomey female soldiers, all of them proud, strong and brave one-breasted

warriors. Meanwhile, (future) physicians are encouraged to select passages of

Lorde’s emotional hemorrhage, which contain vital lessons on medical ethics.

Both types of reader should also situate the necessary —and not offensive—

anger of The Cancer Journals in the historical past: Lorde’s activism fighting

for the rights of women, Black people and patients during the 1970s.

Searching for knowledge and interpretation of illnesses, (future) physicians gain

more confidence from seeing images than readings texts, much less literary ones.

In their daily practice, they look at the results of blood and other laboratory tests

while contemplating results from imaging technology for the diagnosis and

prognosis of patients’ symptoms and illnesses. In their research done to treat

diseases, they trust information from visually instructive diagrams, curves, tables,

graphs and other forms from data and statistics in peer-reviewed publications.

Unlike conventional narratives relying on words only, the blending between

speech and images in graphic medicine speaks a new message in the same language

of health professionals, and scholars in literary studies should acquaint themselves

with this language. Cancer Vixen is, thus, not only a survival guide to help other

women, but also an effective visual text to be included in vade mecums to train

physicians in observational skills and cancer treatment, while developing their

intuition, empathy and understanding of patients’ personal stories beyond clinical

examinations or hospital encounters. Readers from the health professions can

picture themselves as humans in Marchetto’s graphic medicine and extract valuable

lessons for their own sake to embrace a more humanized clinical practice and to

have healthier interactions with the protagonists of illness: their patients.

Concurrently, scholars in literary studies discover the potential of humor in Cancer

Vixen to narrate the individual experience of being sick, to denounce economic

injustices endured by those with cancer, and to emotionally recover from illness.

Although there have been losses in Marchetto’s life, she survives and writes; thus,

she laughs last.

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Notes

1. Arthur Kleinman defines illness

narrative as “a story the patient tells, and

significant others retell, to give coherence to

the distinctive events and long-term course of

suffering” (1988: 49).

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Received: 06/02/2024

Accepted: 02/07/2024

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