In May 2020, poet and essayist, Anne Boyer, was awarded the Nonfiction Pulitzer Prize for The Undying: Pain, Vulnerability, Mortality, Medicine, Art, Time, Dreams, Data, Exhaustion, Cancer, and Care, a memoir on breast cancer (2019). In 2014, Boyer, a single mother under immense financial pressure, was diagnosed with an aggressive triple-negative breast cancer at age forty-one. The illness and subsequent treatments ravaged her body, rupturing her daily routines, forcing new unpredictabilities into her life with each new symptom. Her book poses important questions around oncologic care and cancer culture more broadly, while offering rich insights from her personal experience undergoing treatment. The Undying reaches beyond the traditional memoir with its structure, lyricism, and formal experimentation, providing a unique cultural and patient perspective for breast cancer clinicians and the medical community at large.

Boyer’s book is nuanced with poetic language, painting a picture of the patient experience well-documented and uniquely analyzed. From the beginning, her memoir is contextualized in a lineage of breast cancer writers, most famously Susan Sontag’s Illness as Metaphor and Audre Lorde’s The Cancer Journals, making The Undying a twenty-first century iteration of these past iconographies on female pain and suffering. However, what makes Boyer’s telling so singular is its aspiration towards literature: a firm belief in metaphor and social change through storytelling. While the book is broken into chapters—“The Incubants,” “Birth of the Pavilion,” “The Sickbed,” through the final “Wasted Life” and “Deathwatch”—the pages within these sections read as prose poems. Memoir intertwines with cultural criticism, history, literary analysis, and even mythology. The success of her work is precisely this range. Boyer seamlessly moves between sharp critique and emotional outpour, perhaps each an attempt to capture the sensation of breast cancer pain. When Boyer is asked to rate her pain on a scale of one to ten, she responds, “the correct answer is always anumerical. Sensation is the enemy of quantification” (52). She makes clear that language is one of the things that might fill the void where numbers fail.

Boyer also criticizes the formal (as in literary structural) problem with breast cancer narratives: the politics of placing “I” and “cancer” in the same sentence. Sontag, as well as Rachel Carson in Silent Spring, wrote impersonally about cancer while having, and then dying of, breast cancer. On the other hand, Lorde’s account is inundated with the “I” and first-person experience, to which Boyer writes: “The silence around breast cancer that Lorde once wrote into is now the din of breast cancer’s extraordinary production of language” (8). The authorial distance Sontag and Carson once sustained is replaced with a sociocultural obligation for women to identify themselves with their illness today.

Thus, the cultural criticism that emerges out of Boyer’s patient experience points to social pressure and the overall impact of receiving oncologic care in a media-ridden, capitalist system. The jumbled nature of the book enables Boyer to dive into the structural harm pharmaceutical companies pose individual patients and families, as well as the ways the for-profit medical institution often displaces the most vulnerable people and amplifies suffering. On her chapter about the cancer pavilion, she writes:

Activity inside the pavilion is transient, impermanent, dislocated. The sick and the partners, children, parents, friends, and volunteers who care for them are kept in circulation from floor to floor, chair to chair. The doctors are assigned a rotation of offices and outposts, and in order to find out where yours is each day, you have to call ahead. Cancer treatment appears organized for the maximum profit of someone—not the patients—which means cancer patients are kept in maximum circulation at a maximum rate (62).

Both first-person and cultural analysis shed light on the various assumptions that are made in clinical encounters, such as financial flexibility or the presence of a spouse or other caretaker at home. Boyer often returns to her single-mother status as an indication of a social class misrepresented and how the ever-optimizing health system neglects women like herself. The coordination of her own oncologic care, in conjunction with childcare, places immense strain on her mental health and financial insecurity, and she relies on her friends who take sick leave or time off to attend to her medical appointments and subsequent care.

Boyer also hones into the hypocrisies of “pink ribbon culture,” showing the pressures for women with breast cancer to present in a particular, often one-dimensional, way. While pink ribbon culture champions survivors, it often obfuscates patient goals, quality of life, and conflates survival with moral success. She writes, “Every month is Pinktober when you have breast cancer, and every actual October is a season of hell. The world is blood pink with respectability politics, as if anyone who dies from breast cancer has died of a bad attitude or eating a sausage or not trusting the word of a junior oncologist” (171).

Boyer’s cultural criticism is searing and forceful, making the personal anecdotes feel, at times, wry and even sarcastic. The tonal turns from criticism to the investigator-like uncovering of the dishonest history of pink ribbon symbolism in the Komen enterprise to her intimate personal memories makes clear that Boyer is neither after pity nor sympathy. Rather, the memoiristic moments become an appraisal of respectability politics in oncologic culture itself. Why isn’t breast cancer a cause for outrage, but instead a means for 5ks and green smoothies and positivity? Why is foregoing chemotherapy for palliative care culturally frowned upon, a reason for disintegrating social support?

The narrative structure enables Boyer to pose these frustrations and questions through both broad and intimate lenses. What results is a book that disobeys genre and traditional nonfiction form. The Undying reads less like a memoir or illness narrative and more like a breast cancer collage in twenty-first century health care. While Boyer offers some guidance on how to read her book, the reading experience is one that requires patience and a relinquishing of control. Style, form, and content surprise and disrupt the reader’s expectations. One could go as far to say that the reading experience itself conjures a disorientation that mimics the state of disease, of constant unknowing and lack of linearity.

What can medicine gain from engaging with this formal experimentation of memoir and criticism? Boyer effectively presents her personal illness within a cultural moment. We learn about twenty-first century vlogger cancer subculture, treatment hoaxes, and reasons for public distrust towards medical authority. We see the larger system that contextualizes Boyer’s illness and health, beyond what traditionally falls under the purview of clinical care. The book offers vital insight for clinicians by creating a window into patient life beyond the confines of hospital walls, revealing the unique challenges of navigating oncologic care amidst misinformation and social media deluge, as well as the difficulty of narrating an illness experience in the limited and pressurized space of a clinic.

Boyer writes: “English lacks an adequate lexicon for all that hurts doesn’t mean it always will, just that the poets and marketplaces that have invented our dictionaries have not—when it comes to suffering—done necessary work” (213). Perhaps what clinicians can gain most from The Undying is new, rich, and thoughtful language for suffering and pain to better understand and communicate with patients and their families.