A clear and consistent protective effect of marriage among patients harboring one of the 10 most clinically significant malignancies affecting Americans” was found in a study analyzing Surveillance, Epidemiology, and End Results (SEE) data for 734,889 patients diagnosed with lung, colorectal, breast, pancreatic, prostate, liver/intrahepatic bile duct, head/neck, ovarian, or esophageal cancer, or non-Hodgkin lymphoma. “For five cancers studied (prostate, breast, colorectal, esophageal, and head/neck cancers), the survival benefit associated with marriage was larger than the published survival benefit of chemotherapy,” noted the study authors.¹

“We were very surprised by this. We certainly suspected that marriage had some kind of beneficial effect, but we didn’t realize it would be this big. That really speaks to the importance of social support in the care of patients with cancer,” the study’s corresponding author, Paul L. Nguyen, MD, told The ASCO Post in a joint interview with lead author Ayal A. Aizer, MD, MHS. “We definitely recognize that chemotherapy is important, but so is making sure that patients actually follow through and get access to therapies and the social support that they need to make it through these kinds of therapies,” Dr. Nguyen said. He is Director of Prostate Brachytherapy at Dana-Farber/Brigham and Women’s Cancer Center and Assistant Professor of Radiation Oncology at Harvard Medical School in Boston. Dr. Aizer is Chief Resident of the Harvard Radiation Oncology Program.

The study was published in the Journal of Clinical Oncology¹ and widely reported by the major media, including The New York Times, USA Today, the Cleveland Plain Dealer, CNN, and NBC Nightly News. “We don’t ultimately know with 100% certainty what marriage is doing for patients, but our suspicion—and we have some data to support this—is that it is to provide support for patients with cancer,” Dr. Aizer said. “I think most of the media outlets have picked up on that, and I think that they have represented the study well.”

Less Likely to Die as Result of Cancer

“Married patients were less likely to present with metastatic disease (adjusted odds ratio [OR] = 0.83, 95% confidence interval [CI] = 0.82–0.84, P < .001), more likely to receive definitive therapy (adjusted OR = 1.53, 95% CI = 1.51–1.56; P < .001), and less likely to die as a result of their cancer after adjusting for demographics, stage, and treatment (adjusted hazard ratio = 0.80, 95% CI = 0.79–0.81, P < .001) than unmarried patients,” according to the study report. “These associations remained significant when each individual cancer was analyzed (P < .05 for all endpoints for each malignancy). The benefit associated with marriage was greater in males than females for all outcome measures analyzed (P < .001 in all cases).” Longer follow-up is needed to determine median overall survival.

Being married may contribute to improved outcomes because spouses may encourage their counterparts to seek medical attention for worrisome symptoms and to undergo definitive treatments. “There are many explanations for the vital question of why marriage is associated with improved cancer-specific survival after adjustment for demographics, stage, and treatment, but the most likely reason is that married patients have better adherence with prescribed treatments than unmarried patients,” the researchers reported.

Particularly Important for Head and Neck Cancers

Just making sure patients get to treatment is important. “We’ve looked at several cancers where that is particularly important, and the one that jumps out at us is head and neck cancer. For this disease, patients have to come in for radiation treatment every day, usually for about 7 weeks, and it is not an easy treatment to tolerate…. So that physical element of having someone not only help manage the side effects, but also get the patient to the doctor on a day-to-day basis, which we know is so important, may be making a difference,” Dr. Aizer said.

“In our clinic for head and neck patients at Dana-Farber, when you meet with your physician, it is in a multidisciplinary setting. Not only is there a surgeon, a medical oncologist, and a radiation oncologist, but there is a social worker who is part of the team, who is always thinking about the social situation of the patient and what kind of social support they may might need,” Dr. Nguyen said.

“The social worker can set up rides for you to get to your treatment, can help you with the logistics so that you can show up every day. We don’t have that in treatment for all disease sites, but in head and neck, it is such an important thing to show up every day for your treatment,” he added.

‘Not Just a Pat on the Back’

Both Dr. Aizer and Dr. Nguyen stressed that the findings of their study should not be construed as “just a pat on the back” for married patients.

“The importance of this study is that it highlights the consistent and substantial impact that features of marriage, particularly social support, can have on cancer detection, treatment, and survival,” the study authors noted. “It raises the possibility that investments in targeted social support interventions aimed at vulnerable populations, such as unmarried patients, could significantly improve the likelihood of achieving cure.”

Dr. Nguyen said, “What we see from this research is that social support really helps. If a patient is single, we might need to help that patient a little more. To me, it is not so much about whether you’re married or you’re single, but more about whether you are coming by yourself to appointments or if there is somebody there with you to support you,” he commented.

“Hospitals should really be focusing on this as a way to potentially improve outcomes among their cancer populations,” Dr. Aizer stated.

Sharing the Emotional Burden

“Having someone to share the emotional burden of the diagnosis and cope with everything that is going on” is also important, Dr. Aizer said.

“Physicians should consider screening for depression among unmarried persons and refer patients to mental health specialists if needed. In addition, physicians should consider closer observation of unmarried patients with cancer to maximize adherence,” the study report advises.

“We know that people who are married in general show lower rates of depression and that patients who are depressed after diagnosis of cancer tend not to adhere to the therapies that are recommended for them. That may be one of the reasons for the differences in survival that we saw in our study,” Dr. Aizer noted.

“If you are psychologically distressed, it is harder for you to think rationally about your decision, make the right choice for your cancer care, and also to just keep your life in order so that you can show up every day for your treatment. That’s a lot of work, a lot that you have to juggle,” Dr. Nguyen said.

“Sometimes unmarried patients with cancer may not be asking for the support that they need. They may not recognize that they really may need more physical and emotional support,” Dr. Aizer said. “We wonder if this is more of an issue with men than women—not asking for the support they may need.” Single women, he said, “may be more effective in rallying support from other sources.”

Care for the Caregiver

“When we assess the patient, we should think about how the caregiver is doing,” Dr. Nguyen said. “That is something that is being taught at a lot more medical schools and in residencies—to really look at the caregiver, who this person’s supports are, and spend some time thinking about them and how they fit into the entire care team as well. To a certain degree, this borrows from the pediatric literature, where in the pediatric setting you are not just the patient’s doctor, but also the parents’ doctor. We are starting to incorporate that kind of thinking into a lot more disease sites, although not necessarily in a formal way,” he added.

“Cancer centers would do well to screen for the at-risk family,” noted an accompanying editorial by David W. Kissane, MD, of Monash University, Victoria, Australia, and Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York.² “The provision of family-focused therapy ought to be a routine outpatient service for couples and families in modern cancer.”

Unmarried Subgroups

In the study, marital status was classified as either married on unmarried and then reanalyzed as married vs single, separated, divorced, or widowed. “When we looked at different types of unmarried patients, we didn’t find any differences among them in terms of how well they did after the diagnosis of cancer, be it what stage they presented at with their cancer, whether they got the treatment that they should receive, and most importantly, did they survive their cancer. The fact that the widowed population—who were once married—did just as poorly as some of the other unmarried groups seems to indicate that there really is something about what marriage is providing, rather than some innate characteristic of people who get married, that is driving the results in our studies,” Dr. Aizer remarked.

It is not known how many people in the unmarried category in the study were in relationships. “They may be dating someone, they may be engaged, they may be in a same-gender relationship in a state where marriage is not recognized,” Dr. Aizer noted, but “those patients would be characterized as unmarried in our study, given the database we used. The fact that all unmarried patients were put together in the same cohort, whether they were in relationships or not, tells us that the differences we saw may be even greater than what we appreciated.” ■

Disclosure: Drs. Nguyen, Aizer, and Kissane reported no potential conflicts of interest.

References

1. Aizer AA, Chen M-H, McCarthy EP, et al: Marital status and survival in patients with cancer. J Clin Oncol. September 23, 2013 (early release online).

2. Kissane DW: Marriage is as protective as chemotherapy in cancer care. J Clin Oncol. September 23, 2013 (early release online).