American Splendor (2003) and Non-Hodgkin Lymphoma

A hybrid biopic in which Paul Giamatti plays Harvey Pekar, a file clerk at a Cleveland VA hospital who turns 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, delays doing anything about it, and is eventually diagnosed with lymphoma. Joyce insists they document the illness as a comic, which becomes Our Cancer Year. Chemotherapy leaves Harvey exhausted, foggy and unsure which version of himself is real, a confusion the film literalises by blurring actor and subject. Joyce carries most of the caregiving and the household. After roughly a year of treatment he is told he is cancer-free. The couple takes in Danielle, a collaborator's daughter, and Harvey retires from the VA at a party filmed with the real family.

Spoilers throughout. Discussing the cancer storyline means discussing how this ends.

The caregiving is unusually well observed. Joyce's exhaustion, her role as scheduler, advocate and record-keeper, and the strain the illness puts on a marriage already short of money are treated as central rather than background. The film is honest that chemotherapy is cumulatively depleting rather than dramatically painful: Harvey sleeps, aches, cannot manage stairs, loses his hair, and becomes cognitively fogged and irritable. It shows him ignoring the lump for months, which is very common real behaviour. The argument over whether making art out of illness is coping or exploitation reflects something true about how patients and carers process a diagnosis. And it refuses to make him noble. He is frightened, self-pitying and sometimes cruel to the person nursing him, which is closer to most people's experience than the usual screen patient.

Staging, biopsy and treatment planning are compressed into a few beats, with no sense of the sequence of scans, node biopsy and pathology that actually determines a lymphoma subtype and stage. The film never names the subtype, which in practice is the single fact that drives treatment and outlook. Follow-up is elided too: 'cancer-free' arrives as a clean line, whereas lymphoma survivors face years of surveillance, and Pekar himself was diagnosed with cancer again later in life. The documentary-drama blurring, effective as it is, gives the treatment year a tidier shape than it had.

Harvey Pekar had non-Hodgkin lymphoma, a cancer of lymphocytes, a type of white blood cell. NCI lists the usual signs as swollen lymph nodes in the neck, armpit, groin or abdomen, plus fever with no obvious cause, drenching night sweats, unexplained weight loss, fatigue, itching or rash, and unexplained pain in the chest, abdomen or bones. Fever, night sweats and weight loss occurring together are known as B symptoms. The difficulty is that all of these are far more often caused by ordinary infections, which is why people commonly wait, as Pekar did. There is no screening test for lymphoma for people at average risk. No blood test or scan is recommended for people without symptoms, and neither the USPSTF nor CDC recommends any. Detection therefore depends on someone noticing a lump or a symptom that will not settle and getting it examined. A node that persists beyond a few weeks, keeps growing, or is painless and rubbery should be checked. Diagnosis requires a biopsy of the node, because non-Hodgkin lymphoma covers many subtypes that behave and are treated very differently.

A film is not a diagnosis, and a dramatised illness is not a guide to your own. What a story like this is genuinely good for is lowering the barrier to a conversation you might otherwise put off.

If something in your body has changed and stayed changed for a few weeks, that is worth raising with a doctor — not because it is likely to be cancer, but because most of the time it will not be, and finding that out is the point. Where screening exists for a cancer, it is the one thing you can do before anything is wrong at all. See screening and possible warning signs.

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American Splendor is worth watching as a film. It is not a guide to the disease it portrays. The gap between the two is what this page is for — and the thing worth carrying away is that a change which persists is worth a conversation, whatever a story led you to expect.

This page describes a work of film or television for education. It is not medical advice, and nothing here is a judgement of anyone's real medical care. Spotted an error? Please email [email protected].