American Splendor (2003) and Non-Hodgkin Lymphoma

This is a hybrid biopic. Paul Giamatti plays Harvey Pekar, a file clerk at a Cleveland veterans' hospital who turned his grumbling daily life into the underground comic American Splendor, drawn by Robert Crumb and others. The film cuts between dramatised scenes, animation, and documentary footage of the real Pekar and his wife Joyce Brabner commenting on their own portrayal.

Midway through, Harvey finds a lump in his groin. He does nothing about it for a long time. He is eventually diagnosed with lymphoma. Joyce insists they document the illness as a comic, which becomes Our Cancer Year.

Chemotherapy leaves him exhausted, foggy and unsure which version of himself is real. The film literalises that confusion by blurring actor and subject. Joyce carries most of the caregiving and most of the household.

After roughly a year he is told he is cancer-free. The couple take in Danielle, a collaborator's daughter. Harvey retires from the hospital at a party filmed with the real family.

The rest of this page assumes you know how it ends.

Most cancer films put the carer in the background and light them from behind. This one does not.

Joyce's exhaustion is treated as a subject in its own right. So is the job she has taken on without applying for it: scheduler, advocate, note-taker, driver, and the person who remembers what the doctor said. The strain lands on a marriage that was already short of money, and the film does not pretend love absorbs it.

It is honest, too, about the tone of chemotherapy. Not agony, but depletion. Harvey sleeps and aches. He cannot manage stairs. He loses his hair. He becomes fogged and irritable and unpleasant to the person nursing him.

And the film refuses to make him noble. He is frightened, self-pitying and often unkind. That is closer to most people's experience of being ill than the usual screen patient, and it is a kindness to anyone who has behaved badly during treatment and felt ashamed of it.

Harvey finds the lump and does nothing. The film treats this as characteristic of him. It is not. It is characteristic of most people.

Painless lumps are the easiest thing in the body to postpone. There is no pain to force the issue, and there is a ready explanation available: a strain, an infection, a gland that came up with a cold. Waiting feels reasonable at every single step.

That is why the useful rule is a calendar rule rather than a feeling rule. A lump that is still there after two or three weeks needs looking at, whether or not it hurts, and whether or not you have a theory about it.

Here the film's biggest omission is also its most instructive one. It never names what kind of lymphoma Harvey had, and the published accounts of his illness do not name it either. They record a diagnosis of lymphoma in 1990 and a year of chemotherapy.

That vagueness would be unworkable in a clinic. Lymphoma is not one disease. The first split is between Hodgkin lymphoma and non-Hodgkin lymphoma, and non-Hodgkin lymphoma alone covers dozens of subtypes. Some grow so slowly that the first decision is whether to treat at all. Others double in weeks and need chemotherapy starting almost immediately.

Same word, opposite plans. This is why a node biopsy comes before treatment, and why "we are waiting for the pathology" is not a delay so much as the whole point.

The film also tidies the ending. "Cancer-free" arrives as one clean line. In reality lymphoma is followed for years afterwards, and Pekar himself was treated for prostate cancer later in life. He died in 2010.

The National Cancer Institute lists the usual signs of non-Hodgkin lymphoma as swollen lymph nodes, fever, drenching night sweats, weight loss and fatigue.

In practice that means:

• A painless swelling in the neck, armpit, groin or abdomen.
• Fever with no obvious cause.
• Night sweats heavy enough to soak nightclothes or bedding.
• Weight loss you did not intend.
• Fatigue that rest does not fix.

Fever, drenching night sweats and unexplained weight loss occurring together have their own name: B symptoms. They are worth reporting as a set, because they affect how a lymphoma is staged.

The obvious difficulty is that ordinary infections cause all of these far more often than cancer does. Nobody should read this list and panic. What tips the balance is time. Glands go up with an infection and go down again within a few weeks; the ones that matter are the ones that stay, or keep growing.

There is no screening test for lymphoma of any kind, and none is recommended for people without symptoms. No blood test or scan is offered to healthy adults to look for it.

So detection depends entirely on someone noticing something and acting. A node that persists past a few weeks, that keeps enlarging, or that feels firm and rubbery should be examined. Diagnosis then needs a biopsy of the node itself, because that tissue is what tells the subtype apart.

See possible warning signs for what is worth reporting, and screening for the cancers that can be looked for before symptoms appear.

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American Splendor is a very good film about being ill and a bad film about a disease. It is honest about carers, about depletion, and about how badly people behave when they are frightened.

What it cannot give you is the one thing a real patient spends weeks waiting for: the name of the exact subtype. If you are in that wait now, that is what the pathology is deciding, and it is worth asking your team to tell you the full name when it arrives.

This page discusses American Splendor for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email corrections@cancerexplained.org.