This article responds to the call for further research of graphic cancer narratives (Holmes 2014: 160) with a close reading of Teva Harrison’s In-Between Days (2016). Harrison’s graphic narrative, which traces her experiences living with a breast cancer diagnosis, quickly received popular acknowledgment (e.g. Melgaard 2016; Underwood 2016). Still, interest from scholars of both health/medicine and comics studies has been slower to follow (Nielsen 2019). Since graphic medicine can be defined as “the intersection of the medium of comics and the discourse of healthcare” (Czerwiec et al. 2015: 1), it is necessary to approach the image and text work in Harrison’s graphic memoir from an interdisciplinary perspective. In this case, the team of authors includes an Eisner-nominated comics scholar, who has published on themes of disability and illness, and a nurse practitioner, who currently works in palliative care but who also has extensive experience in oncology and hospice. Together we thus hope to pair “the principles of narrative medicine with an exploration of the visual systems of comic art, interrogating the representation of physical and emotional signs and symptoms within the medium” (Czerwiec et al. 2015: 1).
Teva Harrison’s In-Between Days is hardly the only graphic memoir about living with breast cancer. Existing criticism has looked at other comics narratives such as Miriam Engelberg’s Cancer Made Me a Shallower Person: A Memoir in Comics (2006) and Marisa Acocella Marchetto’s Cancer Vixen: A True Story (2006) (on the former see El Refaie 2012: 144–45; Czerwiec et al. 2015: 158; on the latter see Myers 2015: 90, 93–104; on both, see Green 2015: 71; see also Veta Salubi’s “Saving Grace,” discussed in Czerwiec et al. 2015: 171). Pushing beyond Anglophone contexts, scholars from Iberian studies, for example, have analyzed the graphic breast cancer narrative Alicia en un mundo real (2011), by Isabel Franc and Susanna Martín (Aramburu, 2019; DiFillippo, 2019). While such works necessarily present differences in both the experiences represented and also the formal aspects of comics—such as graphic style and page layout—they also have much in common.
In general, these graphic narratives can be categorized as autobiographical comics that portray themes related to women’s social and individual embodiment (Chute 2010; El Refaie 2012; Szép 2020). More specifically, however, they emphasize responses to the social stigma associated with disease. As do these other creators, Teva Harrison grapples with “the dichotomization of physical disease and social suffering” (Frank 2016: 9). Susan Sontag famously called illness the “night side of life.” It is “a more onerous citizenship,” she wrote. “Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick” (Illness as Metaphor 1990: 3). One might think of these comics as chronicles of and commentaries on this dual citizenship. Rather than accept the notion of the “universal patient” (Czerwiec et al. 2015: 2) or the “objective case study” (Czerwiec et al. 2015: 3), each comics artist crafts a response that is unique in terms of its narrative presentation, graphic style, and formalist aesthetics. The reader’s response is equally individualized. In the words of Arthur Frank, “As a storyteller adapts discourses to fashion a tale she can call her own, she invites others to do the same” (Frank 2016: 18).
Harrison makes a unique contribution to narratives of graphic medicine through both the content and the formal aspects of her work. As with other breast cancer comics, there is a pedagogical value to her perspective. Ian Williams has written that “What is captivating about the best graphic pathographies is that they contain precisely the information that is left out or never considered for inclusion in textbooks” (2015: 132). The text, image and narrative qualities encountered in In-Between Days reveal aspects of the patient experience that may elude healthcare providers. Integration of palliative education and communication skills training have increased since Institute of Medicine’s report Dying in America (2015) was published, however gaps persist between classroom learning and real-world practice. Further, the constraints of the American medical system limit the time providers can spend with patients to truly understand the illness experience. Thus, providers often overlook the symptoms the patient deems most distressing by prioritizing other exam findings (e.g. neutropenia versus alopecia). In comics, symptoms are presented in rich detail and considered over a longer duration than might always be possible to relate in a single appointment. Anxieties involving scans and test results commonly have more space to unfold outside of visits to healthcare institutions. Many patients experience “scanxiety,” a fear of recurrence that will show up on their surveillance or restaging imaging. Harrison brings these subjective experiences and interior thoughts to the page with remarkable clarity.
A. David Lewis has created a subgenre typology for use in the analysis of cancer comics that is quite helpful for understanding In-Between Days. In his poster presentation titled “Cancer and comic books: Distinguishing the subgenre” (2018), he outlines how cancer comics can be classified as experiential, fictive, familial and/or clinical. Lewis’s dynamic model allows for both a primary and a secondary classification. Harrison’s graphic novel can be compared with Marchetto’s Cancer Vixen—to which we refer below throughout this analysis—which Lewis categorizes as primarily experiential and secondarily clinical. In-Between Days is similarly experiential, but also tends toward the familial, given her discussion of family history and the impact of her metastatic cancer on her relationship with her husband David. While not as clinical as Cancer Vixen, Harrison still discusses treatment sequela in clinical terminology.
Beyond making instructive and emotional contributions to the growing literature on patient experiences, In-Between Days also connects with innovative concepts in both cancer treatment and comics studies. First, Harrison’s comics narrative resonates with the notion of “metavivorship” (Tometich et al. 2020), survivorship issues which arise in those living with metastatic disease. “Metavivors are people living with cancer as a chronic and terminal illness. They face unique challenges including an uncertain prognosis, management of acute and chronic symptoms, financial burden and the need for caregiving by family and friends” (Tometich et al. 2020: 2). The “3-P” model of metavivorship focuses on “predisposing,” “precipitating” and “perpetuating” factors that can lead to better or worse outcomes for patients. By enlarging the frame within which survivorship is viewed—i.e., by attending to a close analysis of “longer-term biological, psychological, behavioral, and social changes” experienced by patients—the unique challenges faced by individuals can be more carefully considered (Tometich et al. 2020: 2). The extended timeframe of Harrison’s graphic memoir prompts readers to reflect on these longer-term changes as they emerge and evolve over time. This includes the periods prior to, during and after treatment.
Harrison’s volume also provides an excellent example of what can be called “narrative repair” (Nielsen 2019), which is the ability of comics to serve as a vehicle for processing the trauma related to the difficult psychological and social circumstances that arise with illness. In Disrupting Cancer Narratives: Stories of Rage and Repair, Emilia Nielsen approaches this concept of “narrative repair” as an ongoing practice, not a final result. She emphasizes the “poesis” of repair, that is, “repair as a doing, a ‘making’ and a narrative endeavor” (Nielsen 2019: 140). Although her study includes prose narrative and is not focused specifically on comics, she does explain that “For Harrison, a breast cancer diagnosis is complex because it thrusts her into an ongoing relationship with cancer whereby, rather than expect recovery, she must instead learn to live with the disease for the rest of her radically shortened life. Here, she does not draw and write to ‘cure’ or even ‘heal’ herself but instead to illustrate the performances of the everyday reality of living with cancer” (2019: 141). Nielsen’s insights into In-Between Days are brief, but certainly worthy of further exploration. While Nielsen refers to Harrison’s work as “a series of stark black and white comic strips” (2019: 142), it is necessary to approach the subject with even greater precision, moving beyond the notion that it is a “comic strip” toward a more nuanced understanding of the artist’s formal design innovations. In truth, Harrison never settles into a strip format and is instead always playing with page layout. One might say that her aesthetics is never settled, but instead constantly evolving and changing, like cancer itself, perhaps. In this way, Harrison’s page design mirrors the psychological process of the patient experience.
The Patient Experience in In-Between Days: On Symptoms and Scanxiety
Teva Harrison (1976–2019) died in April 2019 at the age of 42 due to complications from breast cancer. Beyond publishing In-Between Days, Harrison also authored Not One of These Poems Is About You (2020a). This slim volume of poetry presents many overlaps with the themes of her graphic novel. For example, in the brief poem titled “Sustenance Song” (2020a: 55), she reflects on her lack of appetite and mortality (“I eat more when I’m with people/These days, I’m not with people much/So how long, how long, until I disappear?”). The severity of this powerful three-line poem provides a counterpoint to the humor she brings to the topic in the comics form of In-Between Days (e.g. “The Cancer Weight Loss Plan,” 2016: 54). Similarly, the poem “The Things I Do to Keep Cancer on the Down-Low” (2020a: 20–21) addresses the “the dichotomization of physical disease and social suffering” (Frank 2016: 9) by contrasting her external appearance and her internal cancer burden (see the comics in In-Between Days titled “Cancer Fraud,” “Invisibilities,” and “Trying on Small Talk,” 2016: 24, 110, 114). Invoking what Sontag called illness as metaphor, Harrison’s poetic voice states that “No line of demarcation protects me: I live/with a merciless invader who stalks me, endlessly” (2020a: 21). Complementing the central ideas of these introspective poems, In-Between Days can likewise be thought of as a chronicle of the biological, psychological, behavioral, and social changes that emerge as the author and artist lives with metastatic breast cancer and its symptoms.
In-Between Days is organized into three parts, each of which is subdivided into three sections. These then contain a number of smaller reflections: Part One (Diagnosis, Treatment, Side Effects), Part Two (Marriage, Family, Society), Part Three (Hopes, Fears, Dreams). This way of organizing the volume of text and image work has the effect of emphasizing the process of beginning. With each part, with each chapter, with each individual reflection, Harrison re-initiates her narrative. This way of thinking about her situation, foregrounds the iterative and even recursive character of contemplation. As she returns again and again to this task, the act of beginning again becomes polysemic. This notion of constantly beginning again conveys the rhythm, the ups and downs, of living with her diagnosis. Some beginnings are energetic, while others are world-weary and suggest her fatigue.
Harrison’s focus on beginnings creates opportunities to play with the paratextual elements of comics art (see Baetans & Lefèvre 2014). Paratextual elements (i.e. title pages, foreword, afterword, covers, page margins and the like) are spaces that do not signify in prose literature, but that can and should be considered part of the narrative in comics. She designs the title pages that announce parts one, two and three as double-page spreads with a wallpaper feel. A single complex image whose content and symbolism evoke the themes of the part in question is repeated. In all three instances (2016: 4–5, 72–73, 120–21) the repeated images cover a full page and most of the second. As the reader reads left to right across the double-pages, these images encroach on the handwritten title (“Part One”) at the far-right margin and suggest enclosure (see Figure 1). This crowding of page space conveys the feeling of being overwhelmed. The title-page image for each part anticipates and includes the images used in the title pages for the sections that follow. For instance, Part One’s combined image contains a stethoscope (later used to introduce the “Diagnosis” section), syringes (“Treatment”), and a prescription bottle (“Side Effects”). In each one, Harrison integrates three individual components into a unified design, adding decorative lines to create a figure that looks quite like a fleur-de-lis or family crest. For example, the image for Part Two’s title page integrates wedding bands (“Marriage), cake (“Family”) and flowers (“Society”), while the one she produces for Part Three combines balloons (“Hope”), skulls (“Fears”) and a flower (“Dreams”). At the same time, each figure has the symmetry of an inkblot image or Rorschach test, its two halves appearing to be each the mirror-image of the other. Here is a compelling visualization of the duality of disease (as per Sontag 1990; Frank 2016). These two effects together suggest an introspective search for identity, a desire to integrate social and psychological aspects of the patient experience.
Throughout In-Between Days, Harrison addresses and reflects on the symptoms she experiences. Fatigue is, of course, a common symptom in persons with metastatic breast cancer. This often clusters with insomnia and psychological symptoms, including depression and anxiety (Moore 2020). Fatigue can also contribute to changes in cognition and poor memory (Moore 2020). Compared to people with early breast cancer, patients with metastatic breast cancer report poorer quality of life, increased pain and fatigue, and decreased emotional and social functioning (Williamson et al. 2018: 76). They call the late and long-lasting effects of cancer “collateral damage.” Women under the age of 50 experience poorer quality of life and more collateral damage from these late effects of treatment. Married participants reported greater interpersonal concerns than those who were unmarried. Along with fatigue, insomnia is one of the most common symptoms in metastatic breast cancer, with rates up to three times greater than in the general population (Kwak et al. 2020). It is exacerbated by comorbid symptoms, including psychological distress, treatment-related side effects and pain (see “I Can’t Sleep” 2016: 86). Alopecia is a symptom that is distressing to women with breast cancer but is often minimized by healthcare providers (Heinze et al. 2015). In “Splitting Hairs” (2016: 62), she discusses the topic of treatment-related alopecia (see also the reference to hair in “Cancer Gratitudes” (2016: 128).
One of the most commonly presenting symptoms at diagnosis in metastatic breast cancer is pain (Moore 2020; Romano et al. 2022; Willamson et al. 2018). It is often attributed to other causes and can lead to delay in diagnosis (Romano et al. 2022). Additionally, patients can experience chronic pain due to tumor burden and treatment related side-effects (Kwak et al. 2020; Romano et al. 2022; Tometich et al. 2020; Williamson et al. 2018). The text in “Sometimes I Just Break” (2016: 84), references this pain directly: “Inside, there’s pain. So constant that it can fade into the background like white noise. The dull ache of tumours in my bones, like a cavity writ large. Muscles, tense for weeks, knotted from straining to hold myself together. Stomach raw from pills. Hands gnarled into arthritic claws.” In the segment titled “Seeking” (2016: 48), Harrison chronicles her attempts to find the right balance between keeping her pain under control and not sleeping the day away.
The wordless comic “Pain Management” (2016: 42) dramatizes this very balancing act through four large panels (see Figure 2). Reading left to right, the panels are subdivided into two, three and then four internal panels, before ending in an undivided panel frame showing Harrison’s face in close-up. The increasing subdivision carried out inside panels one, two, and three conveys, in formal/structural terms, the increasing anxiety surrounding her pain, that is, the frenetic pace of her now flighty mind as she is less able to concentrate on anything external to her pain. The images—two clock faces, a prescription bottle, and a number of pills—are contained by subpanels whose size and shape match the needs of the object represented (e.g. the tall narrow panel for the Rx bottle, the first narrow subpanel on the page showing Harrison’s darting eyes). In this wordless comic is a compositional unevenness that results from two overlapping layout strategies. The use of four standardized large panels—a “regular/conventional” layout—contrasts with the shifting shape of the subpanels—a “rhetorical” layout (Groensteen 2007: 93–95; following the typology of Benoît Peeters 1998, see chapter two of Case, planche, récit, titled “Les aventures de la page”). The stability of the regular macro-layout and the instability of the rhetorical micro-layout together suggest the persistently elusive nature of finding the right balance in dosing.
Harrison also gives page space to the symptoms stemming from her surgically induced menopause. Her experience of vasomotor symptoms and estrogen deficiency are common complaints in women with metastatic breast cancer (Cole et al. 2022; Moore 2020; Kwak et al. 2020). Readers should keep in mind that “Breast cancer treatments can cause vasomotor symptoms in approximately 30% of post-menopausal women and 95% of pre-menopausal women” (Cole et al. 2022: 4438). Due to the rapid development of either medical or surgical menopause, vasomotor symptoms in pre-menopausal breast cancer patients can be severe and quite distressing (Cole et al. 2022; Kwak et al. 2020; Moore 2020; Romano et al. 2022; Williamson et al. 2018; Mokhtari-Hessari & Montazeri 2020). “The ‘Big Change’” (2016: 58; reprinted in Harrison 2020b: 83), begins with Harrison in the role of stand-up comedian, microphone in hand, talking directly to readers in a confessional mode (see Figure 3). The pacing of the narrative across the twelve-panel grid functions as a comedic bit, complete with set-up, an inventory of symptoms (“hot flashes, cold sweats, thinning hair, vaginismus, dry skin foggy memory and lousy sleep”), and even a punch line in the final frame. A contrast emerges between components of the narration, between the text (recitation) and the image (monstration). This contrast becomes clear as readers move from panel four to five. As Harrison lists off her symptoms, the text shifts from block letters to handwritten script, and the images take on the status of pathognomonic icons. These expand to fill a greater portion of the panel space, and in some cases, overflow the panel borders. The narrative contained in this single comic conveys both a minimization of her symptoms and also her attempt to take them seriously. This juxtaposition suggests her ongoing efforts to acknowledge and integrate her symptoms into her patient experience. By reminding herself of the potential benefits of treatment her symptoms can be more easily endured.
Harrison devotes the comic “Homework” (2016: 64) to one symptom in particular, vaginismus. Here she uses both visual and textual humor to work though the fact that “I’m still in my 30s and I want to have sex with my husband.” In the first panel, she writes that “Menopause made my lady parts close up shop—sex was impossible,” and at right she draws a taco whose word balloon says merely “Nope.” Harrison also includes a comics representation of her gynecologist who gives her as homework, exercises to relax her pelvic floor. In this way she explores the sexual side effects, including dyspareunia, decreased libido and body image changes (Mokhtari-Hessari & Montazeri 2020), that can negatively impact patient relationships with intimate partners.
Patients with metastatic breast cancer also have to live with the persistent fear of recurrent disease. Uncertainty related to scanxiety is a precipitating factor: “Women with metastatic breast cancer report substantial psychological distress due to uncertain prognosis and treatment trajectories” (Tometich et al. 2020: 7). In the text portion of “Sometimes I Just Break” (2016: 84–85), Harrison addresses the stress she undergoes while having to adapt her life into the structure of regular scans: “The excruciating act of scaling back my dreams. Paring down my hopes for this life into three-month bites. Living the enormity of hope and the gut-churning fear that accompany every single scan” (2016: 85; also on scanxiety see Cancer Vixen 2006: 208). The verso single-panel comic shows her embracing her husband David in gratitude for his support (2016: 84). As the complementary image and text of this two-page entry showcase, loved ones and support systems prove invaluable along the way. But love and support do not dispense entirely with the anxiety and “gut-churning fear” of having to await news of metastasis. Rather, these are ever-present aspects of her dualistic experience as a patient.
In “Whac-A-Mole: A Game of Mets” (2016: 20–21), Harrison draws from her citizenship in Sontag’s “kingdom of the sick” to craft a visual metaphor for her scanxiety (see Figure 4). The text at top and bottom of the panel conveys this idea in no uncertain terms: “Living with metastatic cancer is like a game of Whac-A-Mole/There’s no point in trying to cut it out, because it will just keep popping up somewhere else.” Various body parts are visible in the crevices of the arcade game. Readers can clearly see a liver, a femur, a pelvis and the brain. Two additional body parts can be seen in the frame, but are not yet identifiable as they have not yet popped up into view. In this way the visual uncertainty experienced by readers reproduces the uncertainty she experiences as a patient. The font of the title approximates the whimsy of the game itself, but any humor is muted by the circumspect text at the panel borders. The visual metaphor in comics form captures well how patients with metastatic disease sometimes feel they are stuck in a reactive mode.
Metavivorship and Narrative Repair
Those who live with metastatic cancer have more options than to passively resign themselves to what lies ahead. Acceptance of disease is not itself incompatible with a range of active strategies, positive self-talk, and reparative contemplation. “Metavivors demonstrate incredible resilience in the face of uncertainty about the future” (Tometich et al. 2020: 11). They find ways to positively reinterpret situations, practice joy and express gratitude, even utilize hope, which allows them to adapt even in the context of terminal illness. As one anonymized patient has said, “‘The day you lose your hope is the day you start to die’” (Mokhtari-Hessari & Montazeri 2020: 22). There is no surgery or prescription for hope, however. This situation can lead to several possible reactions on the part of practitioners. On one hand, it is possible to feel overly responsible for the outlook that a given patient develops regarding their metastatic disease, while on the other hand, it may be easy to feel as if one can have only little-to-no impact. An emphasis on metavivorship, narrative repair and resilience is indeed compatible with treatment, but this model has the effect of shifting some of the focus away from the practitioner toward the individual patients themselves.
The patient experience acquires a heightened importance in the “3P Model of metavivorship,” as it is outlined by Tometich et al.:
The 3P Model provides a basis for understanding how predisposing, precipitating, and perpetuating factors contribute to the development and maintenance of long-term conditions. Due to its focus on the dynamic interplay of these factors over time, it is an ideal model with which to conceptualize metavivorship. As it relates to metavivorship, the model posits that predisposing factors exist prior to a diagnosis of metastatic disease. Biological, sociodemographic, clinical, and behavioral predisposing factors may contribute to the development of metastatic disease as well as adverse outcomes such as reduced survival, greater symptomatology, and worse quality of life. Precipitating factors are caused by disease and treatment, and include biological, psychological, and behavioral factors. They may be transient, such as distress about one’s diagnosis or acute side effects of treatment; sustained, such as inflammatory processes from cancer or its treatment; or recurrent, such as adverse events resulting from different sequences of therapies. Perpetuating factors are longer-term biological, psychological, behavioral, and social changes due to precipitating factors that can sustain or exacerbate poor outcomes. (2020: 2)
Harrison’s graphic memoir succeeds in tracking the “dynamic interplay” of such predisposing, precipitating and perpetuating factors over time. Though she does not use the word “metavivorship,” this term captures quite well, for example, the representation of her Ashkenazi Jewish genetic predisposition to disease (“The Women of My Family,” 2016: 90; “In My Blood,” 2016: 100), and the psychosocial model of living with illness, accepting it as part of being human, that she received from her grandmother (“Granny’s Legacy,” 2016: 104). As introduced in the previous section of this article, the pages of In-Between Days are filled with the creator’s reflections on the psychological, behavioral, and social changes she undergoes in response to illness, treatment, and its side effects. Most important, throughout, is the mere fact that she is the one organizing her own experiences. That is, this organization is most meaningful when it is carried out by the patient, rather than the practitioner.
Scott T. Smith asks a very pertinent question in his contribution to the Graphic Medicine Manifesto: “Who Gets to Speak?” (2015: 21). By reflecting on the development of contemporary comics scholarship he makes a compelling case for prioritizing inclusion, pluralism, and diversity in the selection and analysis of comics texts (2015: 35). The title of the essay is, of course, an echo of Gayatri Chakravorty Spivak’s “Can the Subaltern Speak?” (1988) and, as such, it foregrounds key questions of autonomy, subjectivity, social power, and social representation, adapting them to the clinical arena. As discussed by Susan Merrill Squier, these values and key questions are also core values of the “fields beyond the medical or health humanities” (2015: 43)—such as women’s studies (2015: 51–52) and disability studies (2015: 49–51; see also Holmes 2014: 148; Chute 2017: 239–274)—that can inform the practice and analysis of graphic medicine. For Squier, the key difference between narrative medicine and graphic medicine is that: “While narrative medicine focuses on the textual and verbal, graphic medicine can access those aspects of illness and medicine that we experience visually and spatially, as enduring, if intractable, aspects of the patient experience” (2015: 46). In this way, graphic medicine participates in a wider shift toward “a critical incorporation of the caregiver’s or patient’s experiences, including the social determinants of health and well-being” (2015: 48).
In In-Between Days it is Teva Harrison the creator and the patient “Who Gets to Speak.” The memoir’s focus on the power that she possesses to construct narrative is what differentiates it from a text like Cancer Vixen, for example. Kimberly Myers has written that when teaching Cancer Vixen, her medical students “pounce[d] on the fact that white coats are present” (2015: 94). By comparison, however, there is a relative absence of white coats in In-Between Days. Similarly absent are depictions of moments of panic that unfold in the hospital setting or the oncology office, specifically (Myers 2015: 100–101). In Cancer Vixen readers see the protagonist taking a friend or voice recorder to an appointment, thus using valuable strategies to assimilate difficult or complex information. By contrast, In-Between Days emphasizes the development of the patient experience outside of the clinical environment. Thus to use Lewis’s terminology it is less “clinical” than Cancer Vixen (Lewis 2018). Beyond the fact that the title of her memoir references her uneven psychological experience, it can also be understood as emphasizing the days in-between appointments, those moments when Teva Harrison ruminates at home rather than in treatment.
Chronicling her patient experiences from diagnosis to radiation and through late-stage disease, Harrison’s memoir invites readers into the difficult psychological process of narrative repair. The comics form is a perfect medium for this endeavor. As Martha Stoddard Holmes (2014) has written, the style of comics art can help readers to identify with its represented characters: “their lack of physical mimesis seems to make the cartoon figures all the more sensitive as conductors of the psychic impact of uncertain and changing diagnoses and social states” (150). In addition, the structural and narrative aspects of comics also play a role in this process of meaning-making: “the reader must extrapolate from fragmentary evidence in order to assign meaning to the sequence” (Smith, 2015: 36, in relation to Nate Powell’s Swallow Me Whole 2008). Emilia Nielsen (2019) applies this general concept to the “difficult life lessons” (22) of In-Between Days, specifically, pointing out that the reader must do work to interpret, to “decide exactly what the lesson is” (142). This work required of the reader of the graphic memoir recapitulates the work required of the patient herself as she processes her illness and forges a narrative of her experiences.
Harrison’s attempts to construct a narrative of what is happening to her appear early in her memoir as she processes the period preceding her diagnosis. The four-panel comic “What’s Wrong With Me?” (2016: 8), includes a text line under its title stating: “Before diagnosis, everybody thought my cancer was something else.” Panels one, two and four show doctors minimizing her symptoms: in the text zones of these panels the artist includes statements such as, “Well-intentioned doctors missed it,” “Once they found a plausible explanation, the doctors didn’t bother to verify” and “You have an ear infection.” The third panel interrupts this pattern with a close-up on Harrison as she feels her own lymph node, a thought balloon questioning “What’s this bump here?” Still, once the pattern is re-established in the last panel on the page, this third panel seems to be evidence that does not appear to fit with what she is being told. The rhythm of this comic itself minimizes her own experience, ceding discursive control to the practitioners she encounters. It wonderfully illustrates the reality that—whether due to leading questions by practitioners, lack of attention, or time constraints—confirmation bias can delay diagnosis and treatment.
“Some People Get Lucky” (2016: 14) shows Harrison in the process of adapting to her new sense of self. As the title suggests, she seeks a way of understanding her diagnosis. She recognizes that she cannot “turn back time, undo my bad luck” (15), yet still it is through narrative that she hopes to find acceptance. The page layout used here makes this one of the most unique comics in the memoir (see Figure 5). It functions in both of two ways.
First, following Andrei Molotiu’s discussion of the iconostatic quality of comics (2012: 91), one can take in the page holistically, as a unified composition, thus at a glance. That is, here Harrison groups together twelve images that are unframed and hover over the white hyperframe of the page. Many are instantly symbolic, visual metaphors of a sort—for example, a four-leaf clover connotes the elusive promise of luck, an older woman with headscarf suggests the old age Harrison will never enjoy, and a pair of dice, the indifferent hands of fate. The texts that accompany each of these twelve pictures themselves exist as part of the image zone. These wrap around the margins of the twelve items being represented, not standing out, but instead emphasizing further the holistic composition of the page. From this first perspective, readers can scan the page, read in any order they prefer, jump to any image that pops out. This visual scanning recapitulates the process of meaning making in which Harrison is engaged.
Simultaneously, the page does indeed have a sequential aspect: the texts form a narrative that can be read left to right, top to bottom. While the images themselves have symbolic meanings individually, these text zones constitute a narrative thread. The words convey more clearly the thoughts that are present in the page’s selection of visual metaphors. Despite diet, alcohol consumption, religion, despite the four-leaf clovers one might find, cancer is a matter of the roll of the dice (as she will say in the title of a later comic, “Cancer Doesn’t Care,” 2016: 28; cf. “The Cancer Guessing Game” from Cancer Vixen, 2006: 34–35). The text thread from the last two images sums up the central message of the comic, picking up where the title left off: “Some people just get lucky/And some people don’t.” The final image shows an anvil landing on a squashed human form. Text and image together convey the crushing feeling that comes as Harrison processes her entry into Sontag’s “kingdom of the sick.”
That there are two ways of reading this single page—i.e. the page’s iconostatic and sequential aspects—foregrounds the role of active interpretation, the effort that Harrison must make toward understanding her circumstances and her new self. The neat rows of images, the careful selection of visual metaphors, and the way that text zones acquire a visual quality, show the artist engaging in narrative as a way of repairing herself. The words here cling to the images, perhaps not yet confident enough to stand on their own. This is a compelling image of the early process of narrative repair. On the way to using language to forge a new story about herself, Harrison’s narrative must grapple with a fundamental ambiguity described by Holmes: “Those diagnosed with cancer are likely to encounter ambiguity in both retrospection and prospection. What was the origin—if not the cause—of cancer?” (2014: 155). The page here conveys this ambiguity in its explicit visual-verbal questioning of cancer’s cause, but also in the disjunctive experience it presents to readers through its nuanced layout.
The process of narrative repair continues throughout In-Between Days, as Teva Harrison learns to “live with the disease” and perform “the everyday reality of living with cancer” (Nielsen, 2019: 141). The memoir’s various segments chronicle her inner thoughts as she undergoes tests and treatments (e.g. an MRI in “Wakeful City,” 2016: 32; radiation in “On a Platter,” 2016: 34), and as she struggles to find hope and gratitude (e.g., “Can’t Be Trusted,” 2016: 70; “Acts of Hope” 2016: 124; “Cancer Gratitudes,” 2016: 128; “Happily Ever After,” 2016: 148). The “poesis” of her narrative repair involves both psychological and corporeal elements. Readers bear witness as she reconnects with her body—the body whose signals had been ignored, pushed aside, prior to diagnosis. The reflective segment “When I Wake Up” captures just such a moment of bodily reconnection well. The purely textual recto page finds Harrison juxtaposing two ideas: “I love to make things with my hands […] cooking to sewing, painting to gardening, everything I most love doing requires my hands”/“And some days, my hands don’t work” (45). The verso comic combines text and image as a way of working through the discomfort caused by this disconnection between her former and current selves (44, see Figure 6). Here one can see the process of narrative repair in both the content and artistic form of the comic.
“When I Wake Up” consists of three horizontal text-image zones arranged vertically on the page. Compositionally, the zones are quite similar. Each contains an image of her two hands, and a brief contemplative text, but the subtle variations among them are most revealing. Together they portray what Squier has called “diachronic time, the perception of time as a flow within which the narrator experiences his or her embodied self” (2015: 46; drawing on Charon and Montello 2002). In the first, upper-most, zone, Harrison writes “When I wake up my hands are deformed claws, my right thumb swells & pops like a broken marionette.” In contrast to the next two zones, this one lacks a rectangular outline. The notable amount of white space preserved at the top of the page signifies the passage from sleep to waking life and suggests the contemplative tone undergirding her ruminations. As it was in “Some People Get Lucky” the written text adheres closely to the outline of the image. The layout and location of this text allows it to rise and fall with the curves of her wrists and points of fingertips. In discussing a similar example from Danny Gregory’s autobiographical comic titled Everyday Matters (2003), Elisabeth El Refaie observes that “following the contours” of a character’s hands the narrative “demonstrates in a rather beautiful way how in comics words and images can become one on the surface of the page” (2012: 42). Along with the point-of-view depiction of her hands, the effect of this compositional strategy is to amplify Harrison’s interest in corporeality. The compositional union of text and image reinforces the thematic union of mind and body. The nature of Harrison’s subject matter draws further attention to a generalized property of comics: the “non-transparency of drawing—the presence of the body, through the hand, as a mark in the text—lends a subjective register to the narrative surfaces of comics pages” (Holmes 2014: 150; citing Chute 2008: 457). The lack of rectangular outline in this text-image zone, and the incursion of the bottom-left text (“My right thumb”) into the panel below it, signal an unformed, rough narrative first coming into being.
Reading downward, the two subsequent landscape panels on the page have greater coherence, suggesting Harrison’s investment in shaping this narrative. Their hand-drawn rectangular frames are a departure from the irregularity of the upper-most zone, and they distinguish the text zone from the image zone with greater clarity. As Harrison continues to reflect on her stiff joints, pain and inflammation, she begins thinking of the future: “I get a few good hours a day & I have to choose how to use them—will I draw?” The placement of the hands is at left in the second panel and at right in the third panel. The fact that they are clasped together in distinct poses, which conveys the action of wringing them, thus evokes what the next page calls “a surging wall of anxiety” (45).
It is of note that the composition of “When I Wake Up” recalls the very first comic of the volume (one that is also titled “In-Between Days,” 2016: 2), where hands also take center stage. The artist’s hands are both represented content on the page and also the vehicle for composing the very memoir we are reading. Drawing is, as Lynda Barry has theorized through her comics (see Szép 2020: ch. 1), a creative enterprise that calls upon the creator’s bodily history. Likewise, the act of reading comics is itself “not only a performance of our cognitive skills, it is also a performance and interaction of bodies” (2020: 1). For Szép, “Comics can thus be thought of as a mediated interaction between three bodies: those of the drawer, reader, and object (the actual comic)” (2020: 5). In “When I Wake Up,” the depiction of hands becomes a way of bringing drawer and reader together. The “actual comic” of In-Between Days forges a link between Harrison’s journey of narrative repair and the reader’s active engagement with that journey. The coordinates of this journey—embodiment, vulnerability, and resilience in the face of illness—are specific to Harrison’s experiences. But the need to forge a narrative to make sense of what happens to us is universal. It is in this sense that Harrison’s memoir, in particular, and the growing market for graphic medicine, in general, is so compelling. As Kristen Gay has written regarding the proliferation of illness narratives, “these struggles to negotiate shifting identities and form narrative structures for unstructured illness experiences may rather be emblematic of the period in which we live” (2016: 171).
Without a doubt, there are far more interesting aspects of In-Between Days than can be meaningfully addressed in a single article-length publication. As comics scholarship delves more into the graphic representation and narrative of cancer experiences, Harrison’s graphic novel also deserves continued attention by practitioners in training. Arguably more than do fictive treatments, the experiential, familial and clinical variants of cancer narrative hold great potential for broadening the clinical student’s understanding of the patient experience. Shared understandings are crucial to better oncologic care, as patients feel better heard and understood. This is particularly important due to the ongoing uncertainties with metastatic disease, including the existential worries surrounding death and dying.
As Harrison’s disease progresses, she continues to craft complex comics metaphors as a way of creating a reparative narrative that best suits her own approach to metavivorship. Readers find her “Managing Anxiety at Home” (2016: 142) and accompany her as she faces her mortality directly (“This disease will kill me eventually,” 155). Her drawing of a black hole in “And Then What?” (117) resonates with the use of cosmic forces and “outer-space perspective” to represent internal crisis that Holmes has analyzed in other graphic novels (2014: 154). “The Dead Bird” (2016: 136) can be read as Harrison approaching an acceptance of death, here setting aside the humor of some previous entries (such as in “Do You Like That,” 68, where she wrote that “Dying of cancer isn’t exactly the sexiest thing I’ve ever done”). But it is perhaps “Incurable” (154), the last image of the memoir, that hits the hardest. In this single-panel comic, Harrison draws herself as a hybrid creature, a griffon, reflecting the duality described by Frank and Sontag’s dual citizenship. She faces away from the reader, her body tilted slightly toward the recto page. Three text blocks state confidently “I Mean…”/“…What”/“Do I Have To Lose?” Understood in the context of the left-to-right reading promoted by the memoir’s multiframe, she comes across as focused on meeting the future she has left, rather than looking backward. This bodily positioning effects a break with the reflective and confessional mode that has dominated up until now. The reparative narrative she has forged has not cured her, but it has done what she needed it to do.
The authors have no competing interests to declare.
Aramburu, D. (2019). A journey through breast cancer: Exploring the body in process in Isabel Franc and Susanna Martín’s graphic breast cancer narrative. Life Writing, 16(3), 397–412. DOI: http://doi.org/10.1080/14484528.2018.1522231
Baetans, J., & Lefèvre, P. (2014). The work and its surround. In A. Miller & B. Beaty (Eds.), The French comics theory reader (pp. 191–202). Leuven University Press. (Original work published 1993).
Charon, R., & Montello, E. (2002). Stories matter. Routledge.
Chute, H. (2008). Comics as literature? Reading graphic narrative. PMLA, 123(2), 452–65. DOI: http://doi.org/10.1632/pmla.2008.123.2.452
Chute, H. (2010). Graphic women: Life narrative and contemporary comics. Columbia University Press.
Chute, H. (2017). Why comics? From underground to everywhere. Harper Collins.
Cole, K. M., Clemons, M., Alzahrani, M., Liu, M., Larocque, G., MacDonald, F., Hutton, B., Piper, A., Fernandes, R., Pond, G. R., Vandermeer, L., El Eman, K., & McGee, S. F. (2022). Vasomotor symptoms in early breast cancer—A “real world” exploration of the patient experience. Supportive Care in Cancer, 30, 4437–4446. DOI: http://doi.org/10.1007/s00520-022-06848-3
Czerwiec, M. K., Williams, I., Merill Squier, S., Green, M. J., Myers, K. R., & Smith, S. T. (2015). Graphic medicine manifesto. The Pennsylvania State University Press.
DiFillippo, E. (2019). Post-op in the real world: Cancer and queer resistance in Isabel Franc and Susanna Martín’s Alicia en un mundo real (2011). In S. Amago & M. Marr (Eds.), Consequential art (pp. 195–219). University of Toronto Press. DOI: http://doi.org/10.3138/9781487531386-009
El Refaie, E. (2012). Autobiographical comics: Life writing in pictures. University Press of Mississippi. DOI: http://doi.org/10.14325/mississippi/9781617036132.001.0001
Engelberg, M. (2006). Cancer made me a shallower person: A memoir in comics. Harper Collins.
Franc, I., & Martín, S. (2011). Alicia en un mundo real. Norma.
Frank, A. W. (2016). From sick role to narrative subject: An analytic memoir. Health, 20(1), 9–21. DOI: http://doi.org/10.1177/1363459315615395
Gay, K. (2016). Breaking up [at/with] illness narratives. In C. Foss, J. W. Gray & Z. Whalen (Eds.), Disability in comic books and graphic narratives (pp. 171–186). Palgrave Macmillan. DOI: http://doi.org/10.1057/9781137501110_12
Green, M. J. (2015). Graphic storytelling and medical narrative. In M. K. Czerwiec et al., Graphic medicine manifesto (pp. 67–86). The Pennsylvania State University Press. DOI: http://doi.org/10.5325/j.ctv14gpf04.6
Groensteen, T. (2007). The system of comics (B. Beaty & N. Nguyen, Trans.). University Press of Mississippi. (Original work published 1999).
Gregory, D. (2003). Everyday matters: A memoir. Hyperion.
Harrison, T. (2016). In-between days: A memoir about living with cancer. House of Anansi Press.
Harrison, T. (2020a). Not one of these poems is about you. House of Anansi Press.
Harrison, T. (2020b). The big change. In M. K. Czerwiec (Ed.), Menopause: A comic treatment (p. 83). The Pennsylvania State University Press. DOI: http://doi.org/10.1515/9780271089096-021
Heinze, S., Williams, P. D., & Bott, M. (2015). Ongoing symptoms reported by breast cancer survivors. Journal of Hospice and Palliative Nursing, 17(2), 157–164. DOI: http://doi.org/10.1097/NJH.0000000000000140
Holmes, M. S. (2014). Cancer comics: Narrating cancer through sequential art. Tulsa Studies in Women’s Literature, 33(1), 147–62.
Institute of Medicine. (2015). Dying in America: Improving quality and honoring individual preferences near the end of life. The National Academies Press. DOI: http://doi.org/10.17226/18748
Kwak, A., Jacobs, J., Haggett, D., Jimenez, R., & Peppercorn, J. (2020). Evaluation and management of insomnia in women with breast cancer. Breast Cancer Research and Treatment, 181, 269–77. DOI: http://doi.org/10.1007/s10549-020-05635-0
Lewis, A. D. (2018). Cancer and comic books: Distinguishing the subgenre. [Poster presentation]. Comics & Medicine Conference, White River Junction, VT.
Marchetto, M. A. (2006). Cancer vixen: A true story. Pantheon.
Melgaard, M. (2016, April 23). Drawing outside the lines: Teva Harrison’s cancer memoir shades in the lonely realities of living with illness. National Post, 4.
Mokhtari-Hessari, P., & Montazeri, A. (2020). Health-related quality of life in breast cancer patients: Review of reviews from 2008 to 2018. Health and Quality of Life Outcomes, 18(338), 1–25. DOI: http://doi.org/10.1186/s12955-020-01591-x
Molotiu, A. (2012). Abstract form: Sequential dynamism and iconostasis in abstract comics and in Steve Ditko’s Amazing Spider-Man. In M. J. Smith & R. Duncan (Eds.), Critical approaches to comics: Theories and methods (pp. 84–100). Routledge.
Moore, H. C. F. (2020). Breast cancer survivorship. Seminars in Oncology, 47(4), 222–228. DOI: http://doi.org/10.1053/j.seminoncol.2020.05.004
Myers, K. R. (2015). Graphic pathology in the classroom and the clinic.” In M. K. Czerwiec et al., Graphic medicine manifesto (pp. 87–114). The Pennsylvania State University Press. DOI: http://doi.org/10.5325/j.ctv14gpf04.7
Nielsen, E. (2019). Disrupting cancer narratives: Stories of rage and repair. University of Toronto Press. DOI: http://doi.org/10.3138/9781487530020
Peeters, B. (1998). Case, planche, récit: lire la bande dessinée. Paris/Tournai: Casterman.
Powell, N. (2008). Swallow me whole. Top Shelf.
Romano, C., Harris, N., Gnanasakhty, A., D’Alessio, D., & Chandiwana, D. (2022). Patient experiences with the patient-reported outcome measures in metastatic breast cancer trials: Qualitative interviews. Journal of Patient-Reported Outcomes, 6(60), 1–12. DOI: http://doi.org/10.1186/s41687-022-00460-z
Smith, S. T. (2015). Who gets to speak? In M. K. Czerwiec et al., Graphic medicine manifesto (pp. 21–40). The Pennsylvania State University Press. DOI: http://doi.org/10.5325/j.ctv14gpf04.4
Sontag, S. (1990). Illness as metaphor and AIDS and its metaphors. Anchor. (Original work published 1978).
Squier, S. M. (2015). The uses of graphic medicine for engaged scholarship. In M. K. Czerwiec et al., Graphic medicine manifesto (pp. 41–66). The Pennsylvania State University Press. DOI: http://doi.org/10.5325/j.ctv14gpf04.5
Spivak, G. C. (1988). Can the subaltern speak? In C. Nelson & L. Grossberg (Eds.), Marxism and the interpretation of culture (pp. 271–313). Macmillan.
Szép, E. (2020). Comics and the body: Drawing, reading, and vulnerability. The Ohio State University Press. DOI: http://doi.org/10.26818/9780814214541
Tometich, D. B., Hyland, K. A., Soliman, H., Jim, H. S. L., & Oswald, L. (2020). Living with metastatic cancer: A roadmap for future research. Cancers, 12(3684), 1–24. DOI: http://doi.org/10.3390/cancers12123684
Underwood, K. (2016, April). Teva Harrison: On cancer, optimism and how to (gracefully) talk to a sick person. Chatelaine, 22.
Williams, I. (2015). Comics and the iconography of illness. In M. K. Czerwiec et al., Graphic medicine manifesto (pp. 115–42). The Pennsylvania State University Press. DOI: http://doi.org/10.5325/j.ctv14gpf04.8
Williamson, T. J., Love, S. M., Clague DeHart, J. N., Jorge-Miller, A., Estraghl, L., Cooper Ortner, H., & Stanton, A. L. (2018). Metastatic Breast Cancer Collateral Damage Project (MBCCD): Scale development and preliminary results of the Survey of Health, Impact, Needs, and Experiences (SHINE). Breast Cancer Research and Treatment, 171, 75–84. DOI: http://doi.org/10.1007/s10549-018-4823-x