American Splendor (2003) and Non-Hodgkin Lymphoma

This page is for readers who have seen, or plan to see, American Splendor. It looks at how the film shows lymphoma and caregiving, and what NCI says about the signs of lymphoma.

This is a hybrid biopic. Paul Giamatti plays Harvey Pekar, a file clerk at a Cleveland veterans' hospital. Pekar 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. In that footage, the real Pekar and his wife Joyce Brabner comment 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. It is also 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. There is also 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 a lump that does not go away should be checked by a doctor, 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 has many subtypes. NCI divides them into indolent (slow-growing) and aggressive (fast-growing) types. For some early-stage or symptom-free cases, doctors may recommend watchful waiting, which means close monitoring without immediate treatment. Aggressive types develop rapidly and need prompt treatment.

Same word, different plans. NCI says diagnosis relies on a lymph node biopsy, so waiting for the pathology is part of the process.

The film also tidies the ending. "Cancer-free" arrives as one clean line. After treatment, follow-up appointments and tests continue, so ask your team what yours will look like. Reports at the time of his death said Pekar also had prostate cancer. 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:

• Swelling in the lymph nodes in the neck, underarm, 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 together to your care team.

Many of these signs also have other, less serious causes. Nobody should read this list and panic. But if swollen nodes, fever, night sweats or weight loss stay or keep getting worse, call your doctor. Call your care team right away if you have a fever of 100.4 F or higher during cancer treatment.

NCI's information on non-Hodgkin lymphoma describes diagnosis starting from symptoms, followed by a lymph node biopsy, and does not describe a routine screening test for people without symptoms. Ask your care team if you have questions about your own risk.

So detection depends on someone noticing something and acting. A node that persists or keeps enlarging should be examined by a doctor.

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. 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.