Cancer as Chronic Condition

Before scanning, notice the words that stop working when cancer becomes chronic:

• "Cure" — presumes an end point. Gone, if treatment is indefinite.
• "Survivor" — survived what, if it's ongoing? The identity has no anchor.
• "Remission" — a pause between acute episodes; doesn't fit continuous management.
• "Beating cancer" / "the fight" — the war metaphor presumes victory or defeat; chronic management is neither.
• "Patient" — implies an episode of care, not a permanent state of being.

When the vocabulary breaks, the lived experience has nowhere to sit. Part of the H3 transition is inventing new words — as "managing" diabetes gave people a non-tragic way to hold a lifelong condition.

Try it yourself

List the words your topic relies on that would *break* in its
transformed future (for cancer: cure, survivor, remission, the fight).
A category whose vocabulary breaks is one whose lived experience has
nowhere to sit. New words are part of the transition.

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H1 — The acute "cure-or-die" model (fading)

• Cancer as an acute crisis: diagnose, treat hard (surgery/chemo/radiation), then either "cured" or terminal.
• Identity binary: "survivor" or "lost the battle."
• Care organised in episodes; insurance and work built around a treatment period with an end.

Signs of fading:

• More cancers becoming long-term-survivable / manageable via targeted and immuno-therapies. (1)
• Liquid biopsy enabling continuous monitoring rather than episodic scans. (1)
• Growing survivorship populations living many years post-diagnosis.

H2 — The messy coexistence (now)

• Some cancers cured, some terminal, some managed indefinitely — all at once, often within one clinic.
• Patients oscillating between "cure-seeking" and "management" framings; doctors too.
• Systems (insurance, work, identity) built for H1 straining to handle H3 patients.
• ctDNA-guided treatment to prevent relapse and avoid overtreatment — the ambiguity institutionalised. (1)

H3 — Cancer as managed chronic condition (emerging)

• For a growing set of diagnoses: cancer like diabetes — monitored continuously (liquid biopsy), treated with adjustable long-term regimens, lived with for decades.
• New identity: not "survivor," not "terminal" — managing. A permanent, non-tragic patienthood.
• Care continuous, not episodic; insurance and work redesigned around decades-long conditions.
• New vocabulary and rituals for a state the old words can't name.

The H2 reading

The hard part isn't H1 or H3 — it's living in H2, where the same person may be told "we're trying to cure this" and "we're managing this indefinitely" in the same year, and where every institution (work, insurance, family, the patient's own self-image) is calibrated for a binary that no longer holds. The transition's pain is concentrated in the messy middle — which is exactly where most patients actually are. The Three Horizons insight: we under-support the people in H2 because our systems are built for H1 and our hopes are pinned on H3.

Try it yourself

Map your topic in Three Horizons. For a condition-transition like this:
- H1: the acute/binary model + signs of fading
- H3: the managed-chronic model + emerging signals
- H2: the messy coexistence — and who is stuck living in it now
The key insight is often that H2 (the present) is under-supported
because systems are built for H1 and hopes pinned on H3.

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If cancer becomes chronic (H3), several systems must reorganise — each a design problem:

1. Identity. "Survivor" → "managing." A whole culture of pink-ribbon triumph-or-tragedy narratives has no slot for "I'll be in treatment for the rest of my life and that's... fine, mostly." New stories needed.
2. Work. Episodic "medical leave then return" → permanent accommodation for someone in indefinite treatment. The year-twelve-of-treatment worker is a new category employment law barely recognises.
3. Insurance & cost. One-time treatment episode → decades of high-cost therapy. Lifelong treatment subscriptions; insurance models built for acute episodes break; who pays for 25 years of a targeted drug?
4. The clinic. Episodic oncology → continuous monitoring-and-adjustment, more like endocrinology (diabetes care) than acute oncology.
5. The family & the self. Living with permanent uncertainty (the biopsy every quarter) becomes a long-term psychological condition of its own.

These are exactly the systems the Design Fiction artifacts will probe.

Try it yourself

List the systems your transition reorganises (identity, work, insurance,
care delivery, family/self). Each is a design problem and a potential
artifact. Flag the one society is least prepared for (here: decades-long
treatment cost, and the "managing" identity).

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We design into the H3 world (with one foot in H2's friction) and produce the three artifacts the brief names. All constructed.

Artifact 1 — The cancer management plan renewal letter

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NORTHfield Oncology — Chronic Cancer Management Service

Annual Management Plan — Renewal & Review

Patient: R. Okonkwo · Condition: Metastatic [redacted], managed · Year on plan: 12

Dear R. Okonkwo,

Your liquid-biopsy panel this quarter shows stable disease — ctDNA within your managed range. No change to your regimen is indicated.

This letter renews your Management Plan for a further 12 months:

• Quarterly ctDNA monitoring (home blood-draw kit; clinic review by call)
• Continue current targeted therapy (see subscription, enclosed)
• Annual imaging; psychological-support sessions as you choose

A note on language. We no longer describe your status as "in remission" or "cancer-free." You are managing a chronic cancer, stably, as you have for twelve years. This is a good outcome. Many patients find the absence of an "all-clear" hard; our counselling team is here for exactly that.

You are not waiting for an end point. You are living, with monitoring.

— Dr A. Mensah, Chronic Cancer Management Service

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What it argues: The line "you are not waiting for an end point — you are living, with monitoring" is the H3 identity in a sentence. And "we no longer describe your status as 'in remission' or 'cancer-free'" makes the vocabulary break (Step 1) institutional — the clinic has had to invent new language because the old words wounded. Twelve years in, the patient is neither survivor nor dying. The letter is gentle and quietly radical.

Artifact 2 — The year-twelve workplace accommodation request

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Workplace Adjustment Request — Chronic Health Condition

(Under the Long-Term Conditions at Work Framework)

Employee: R. Okonkwo · Manager: [name] · Request type: renewal/ongoing

This is not a request for medical leave. I am not ill in the episodic sense. I have a managed chronic cancer (year 12) and request the same standing adjustments as previous years:

• One half-day per quarter for monitoring (not "sick leave" — routine)
• Flexibility on fatigue days (variable, ~2–3/month)
• No requirement to disclose my condition to the wider team

Please note: there is no "recovery date" to put on this form. The form asks "expected return to full duties." I am at full duties. The form was built for a different kind of illness. I have written "N/A — ongoing" in that box, as I have for eleven years.

Signed, R. Okonkwo

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What it argues: "The form was built for a different kind of illness" — the artifact's power is that the bureaucracy itself is an H1 artifact failing an H3 person. The "expected return to full duties / N/A — ongoing" box is the whole H1→H3 mismatch in one field. The employee is fully productive, permanently accommodated, and quietly fighting a form that assumes illness ends.

Artifact 3 — The treatment subscription invoice

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VERTEX THERAPEUTICS — Patient Therapy Subscription

Invoice — Quarter 4, Year 12 · Patient ref: RO-2029-44

Item	Amount
Targeted therapy (90-day supply, auto-renew)	$14,200
ctDNA monitoring panel (×1)	$890
Patient-support programme	$0 (included)
Covered by your plan	−$14,420
Your contribution this quarter	$670

Lifetime therapy value to date (Years 1–12): $681,400.

Continuity guarantee: under the Chronic Therapy Continuity Act, your subscription cannot be discontinued for cost while clinically indicated, and your contribution is capped at the annual chronic-condition ceiling.

Auto-renews in 90 days. This is treatment #48 in your continuous course.

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What it argues: "Treatment #48 in your continuous course" and "lifetime therapy value: $681,400" make the economics of indefinite treatment visceral. The "Continuity guarantee / Chronic Therapy Continuity Act" is the constructed policy that makes H3 survivable — without it, chronic cancer is a death sentence by un-affordability. The invoice quietly poses the question: who pays for decades of $14,000-a-quarter therapy, and what happens to those without the Act's protection?

Why the three together pull weight. Each artifact catches a different system failing-or-adapting to the new identity: the clinic inventing language (Artifact 1), the workplace fighting its own form (Artifact 2), the economy needing a new law (Artifact 3). Read together, they make "cancer as chronic condition" not an abstraction but a life — R. Okonkwo's, twelve years in, fully alive, permanently managing, held up by bits of paper that are only half-designed for them.

Try it yourself

Produce 2–3 Design Fiction artifacts that each catch a *different system*
adapting to your transformed condition (clinic / workplace / economy).
In each, find the spot where an H1-era form or word *fails* the H3
person ("N/A — ongoing"; "we no longer say remission"; "treatment #48").
The failure points are the argument.

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Object from the World. The home ctDNA draw kit — a small quarterly blood-draw device that arrives by post, that R. Okonkwo uses at the kitchen table, that turns "going to hospital for scans" into "a Tuesday morning ritual at home." The object domesticates cancer monitoring the way a glucose monitor domesticated diabetes — and carries the same quiet weight: every quarter, a small moment of dread waiting for the result.

Bodystorming. A 10-min enacted scene: results day, year 12. Roles:

• R. Okonkwo, doing the home draw, waiting for the app result, performing calm.
• Their teenage child, who has never known a parent without cancer — for whom this is simply normal, which is its own poignancy.
• A friend who still uses H1 language ("but are you cured yet? when's your all-clear?") and means well.
• The app, delivering "stable disease" — relief that is not joy, because there's no finish line.

Prompts to enact: What does Okonkwo's body do in the gap between draw and result? How does the child move through the kitchen — casually, because it's normal? Where does the well-meaning friend's H1 question land?

Bodystorming surfaces what the artifacts can't: the texture of permanent low-grade uncertainty, and the generational shift (a child for whom managed-cancer-parent is simply the world) — the emotional reality of H3 that no document holds.

Try it yourself

Describe the domestic Object your H3 world produces (the home monitoring
kit). Bodystorm a 10-min "results day" scene. Include someone for whom
the new normal is simply *normal* (a child), and someone stuck in H1
language. Debrief on the emotional texture the artifacts missed (here:
permanent low-grade uncertainty; relief-without-joy).

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• Participants: 6 — an oncologist, a cancer patient or survivor, an HR manager, a health-insurance actuary, a patient-advocacy worker, someone who lost a family member to cancer. (Compose with great care; this is heavy.)
• Setup: Hand out the three artifacts. No briefing.
• Run: 10 min read. 10 min — each notes the line that moved or unsettled them. 20 min — discussion around two questions: "What does 'survivor' mean here?" and "Who can afford this future, and who can't?" 10 min reveal & debrief (2040, H3).
• Looking for: the patient/survivor's reaction to "we no longer say remission" (relief or loss?); the actuary's reaction to "lifetime value $681,400" and the Continuity Act (is H3 even insurable?); the bereaved participant's response to a world where this cancer is managed but theirs wasn't. The equity question (Artifact 3) is the one that should haunt the room.
• Harm note: This is among the most emotionally loaded prototypes in the set. Genuine consent, genuine outs, a facilitator able to hold grief.

Try it yourself

Design a 50-min prototype around the three artifacts. Two questions:
what does "survivor" mean here? who can afford this future? Compose the
group so lived experience is present, with real care and outs. Watch
the equity question (who's priced out of H3) — it should haunt the room.

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1. What did Three Horizons + the cascade surface? — That the medical transition (H1→H3) is the easy part; the hard parts are identity (new words for "managing"), the messy H2 middle (where most patients actually live, under-supported), and cost (H3 is only humane with something like the Continuity Act).
2. Where did the H3 world flatter itself? — It assumes the therapies keep working for decades and that the Continuity Act exists. Without affordability protection, "cancer as chronic condition" is a privilege of the insured — a brutal two-tier outcome.
3. Whose experience did you not centre? — Those with cancers that don't become chronic (still acute, still fatal), who may feel erased by a triumphant "chronic" narrative; and lower-income-country patients for whom even H1 care is out of reach.
4. What 2026 action does this surface? — Build the survivorship/identity support and vocabulary now (the "managing" identity); design workplace and insurance frameworks for indefinite conditions; address drug-cost sustainability before chronic cancer becomes common, so H3 isn't only for the wealthy.
5. What does this refuse? — To promise cancer becomes chronic for everyone (many cancers won't). To treat the medical advance as the whole story. To ignore who's priced out.

Try it yourself

Reflect in <60 words each: what did the cascade surface that a "cure
timeline" question wouldn't; where did the H3 world flatter itself;
whose experience did I not centre; what 2026 action follows; what does
this refuse to do?

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