According to various studies that draw data from the Surveillance, Epidemiology, and End Results (SEER) program, unmarried patients are less likely to survive cancer. These findings have made headlines in recent years; however, it has also led a number of biases held by members of the oncology community to come to light. Because unmarried patients are less likely to choose surgery or radiotherapy treatments over other interventions, some clinicians and researchers speculate that those patients have less “fighting spirit” or that having a life partner would give them “more to live for.” In a report published in the New England Journal of Medicine, one researcher describes her own experience undergoing treatment for cancer as an unmarried person and discusses whether the assumptions clinicians make about unmarried patients are at all founded.
When Dr Joan DelFattore was exploring treatment options for stage IV gallbladder cancer in 2011, she encountered a situation that drew her attention as a researcher. During a meeting with a surgeon, she was questioned about her support system to which she gave an answer that seemed to satisfy her surgeon. At a later meeting with a medical oncologist, she was quizzed again. This time, the doctor was concerned to hear that she was unmarried. Despite Dr DelFattore’s insistence that she had support from those around her, the oncologist recommended the less rigorous of 2 treatment options based on wanting to avoid serious side effects because of “her situation.” Dr DelFattore sought another opinion and eventually underwent the more rigorous treatment, which was successful. Curious as to whether this was an isolated incident or one more frequently encountered by patients without traditional support systems, she turned to existing medical research to understand more about how unmarried people with cancer are treated.
While researching, Dr DelFattore found 84 studies that use the SEER program, a database that compiles data from millions of people with cancer. The studies offer a view of marital status as an indicator of prognosis, but are limited in that they do not consider additional factors such as whether the patient lives alone or any information about the availability of family members. Another study discussed that “married patients display lower risk of depression,” citing a statistic that says only 4.3% of US spouses are depressed compared with 11% of divorced or separated adults. According to Dr DelFattore, these conclusions are not well justified when considering data such as that from PsycINFO and Sociological Abstracts databases, which explain that the benefits of marriage are dependent on “a range of individual, interpersonal, and structural characteristics.” In a Mayo Clinic initiative that implemented universal screening of patients with cancer, there was no association found between depression and marital status. According to Dr DelFattore, this body of medical literature equates the absence of a spouse with lower rates of surgery and radiotherapy, which in turn may affect perceived survival rates of married vs unmarried people with cancer. One study of people with liver cancer pointed to married patients receiving “better social support,” which “promotes health and survival.” As Dr DelFattore’s research outlines, “social support” encompasses not only spousal support but also the interaction of family, friends, and community.
Although Dr DelFattore acknowledges that married patients may have an increased likelihood of emotional and practical support, neither is guaranteed. Additionally, marital status may be less important to some patient demographics such as younger patients and older female patients. Dr DelFattore points to the need for further research on how the marital status of patients can lead to bias on the part of healthcare providers. Also noted in Dr DelFattore’s research was that they did not discuss physicians’ roles in recommending treatments, and how physicians’ attitudes toward their patients can be affected by marital status. As outlined by her own experience, Dr DelFattore presents the conclusion that the implicit bias existing within the oncology community poses a risk to unmarried patients, who may be denied certain treatments based on their perceived support network or lack thereof.
DelFattore J. Death by stereotype? Cancer treatment in unmarried patients. N Engl J Med 2019;381:982-985.