|Ahead of print
Dispelling myths about unmarried patients with cancer
College of Arts and Sciences, University of Delaware, Newark, DE, United States
|Date of Submission||09-Feb-2020|
|Date of Decision||25-May-2020|
|Date of Acceptance||27-May-2020|
|Date of Web Publication||20-Jul-2020|
College of Arts and Sciences, University of Delaware, Newark, DE
Source of Support: None, Conflict of Interest: None
Since 1973, the Surveillance, Epidemiology, and End Results (SEER) program has amassed data on more than 10,000,000 patients through cancer registries covering approximately 35% of the population of the United States. This database is maintained by the National Cancer Institute, an agency of the United States government.
Among other things, SEER classifies patients by marital status: married, divorced/separated, widowed, and never married. It thus enables researchers to calculate the association between marital status and such factors as disease-specific survival, overall survival, and receipt of surgery or radiotherapy. (Chemotherapy is tracked separately in SEER, with the caveat that because it is administered in diverse outpatient settings, data may not be accurately reported. The articles discussed below relate only to surgery and radiotherapy.)
As of this writing (February 2020), 93 SEER-based articles dealing with the association between marital status and cancer care have been indexed on Medline. Their best-known finding, reported in headlines throughout the United States, is that patients are more likely to survive cancer if they are married than if they are widowed, divorced/separated, or never married. Less widely reported is another finding of these studies: patients who present for cancer care in the United States are more likely to receive surgery or radiotherapy if they are married than if they are not.
The authors of these studies report two limitations worthy of note. First, SEER does not track cohabitation outside of marriage. Second, SEER tracks marital status at initial diagnosis only; it does not track subsequent changes in marital status. Also of note, these articles focus specifically on marital status. Other bodies of medical literature study treatment discrepancies based on other demographics, such as race  and sex.
In the absence of objective evidence explaining why treatment rates are associated with marital status, the authors of these articles propose explanations based on widespread, deeply held assumptions about unmarried adults that are in fact unsubstantiated. Let us consider two of the most frequently repeated of these assumptions: patient choice and lack of social support.
| » Patient Choice|| |
Many of these SEER-based articles speculate that unmarried patients must be refusing treatment, thus accounting for lower rates of surgery and radiotherapy as compared with married patients. Without a spouse, these authors suggest, patients lack a “fighting spirit” and even the will to live. By contrast with these unsubstantiated speculations, a study of almost a million patients conducted by researchers at the Harvard Medical School and the Mayo Clinic, among others, revealed that only 0.52% of unmarried patients refused surgery when it was offered, and 1.33% refused radiotherapy. Although the rates for married patients were even lower, refusal rates below 1% and 2% clearly discredit the assumption that unmarried patients may be expected to decline treatment.
Lack of social support
With few exceptions, these SEER-based articles suggest that solely by virtue of being unmarried, patients may be assumed to lack the social support necessary to handle challenging cancer treatment. As evidence—when evidence is offered at all—these authors cite psychological and sociological studies that allegedly justify using marital status as a proxy for social support. In reality, these psychological and sociological studies explicitly state that social support can be understood only in terms of multiple factors, and that no one measure, such as living alone, can be used as a shortcut to assess social support. Indeed, a psychological review article repeatedly cited in this SEER literature is so far from equating social support with marriage that it does not even mention the words “marriage,” “marital,” or “spouse.”
In addition to misrepresenting studies of multifaceted social support as if they pertained only to marriage, the authors of these SEER-based articles ignore an extensive body of research showing that many single adults have close relationships with extended family, friends, and neighbors. Moreover, non-spousal relationships have been shown to provide effective functional and emotional support, while stressful marriages are associated with poor health outcomes. The undoubted benefits of healthy marriages, important as they are, do not justify conflating social support with the institution of marriage.
The work of psychologists such as Nobel Prize winner Daniel Kahneman may help to explain why misconceptions about unmarried adults persist despite research that disproves them. Kahneman et al. have shown that implicit, or unconscious, biases affect human thinking by means of heuristics—the mental shortcuts that humans take in order to simplify problem-solving. Two of these heuristics, availability and outgroup homogeneity, are particularly relevant to the medical literature on marital status and cancer.
| » Availability Heuristic|| |
Psychologists have known for decades that people's beliefs depend less on data than on the frequent repetition of widely accepted ideas. As an example, sharks may appear to be a greater threat than toilets are, since shark attacks generate frenzies of media coverage, whereas toilets do not. And yet, National Geographic reports that 13 Americans were injured by sharks in 1 year, while 43,000 were injured by toilets. Beliefs may also be unduly influenced by our own experiences and the experiences of people we know. As a result, humans are likely to perceive reality not in terms of hard facts, but in terms of ideas that come most readily to mind because of frequent repetition or personal experience—hence the term “availability” heuristic.
The availability heuristic clearly applies to the relentlessly repeated stereotyping of unmarried adults. Moreover, authors of SEER-based medical articles have stated in interviews that they themselves depend on their wives for health care. Consistent with the availability heuristic, it is to be expected that medical researchers, clinicians, and other healthcare professionals—like the rest of the human race—are prone to rely on ideas generated by personal experiences and frequently repeated cultural narratives, which come so readily to mind that they appear to be self-evident truths rather than beliefs or opinions that might not stand up to objective testing.
| » Outgroup Homogeneity|| |
Another relevant heuristic is the unthinking assumption that all members of a marginalized social group share the same characteristics, even when that group is, in fact, large and diverse. Since SEER collects its data from population-based cancer registries in the United States, it is highly relevant that 45% of the adult population in the United States is unmarried, and that unmarried persons represent the full range of educational, economic, and social diversity. The simplistic stereotypes presented in these SEER-based articles, although consistent with long-standing social beliefs, cannot provide a useful understanding of data drawn from SEER.
| » Conclusion|| |
Although marital status is unquestionably associated with cancer treatment and outcomes, attempts to explain away the systematic undertreatment of unmarried adults leave much to be desired. Of particular concern is the overgeneralized depiction of unmarried adults in this body of medical literature, together with its misrepresentation of sociological and psychological research and its failure even to consider the possibility of social bias. Clearly, qualitative research is required to assess whether, how, and to what extent social beliefs about unmarried adults may be inappropriately influencing the treatment they receive.
| » References|| |
DelFattore J. Death by Stereotype? Cancer treatment in unmarried patients. N
Engl J Med 2019;381:982-985.
Chowkwanyun M, Reed AL. Racial health disparities and Covid-19 -- caution and context. N
Engl J Med 2020. Published online May 6. doi: 10.1056/NEJMp2012910.
Locke JE, Shelton BA, Olthoff KM, Pomfret EA, Forde KA, Sawinski D, et al
. Quantifying sex-based disparities in liver allocation. JAMA Surg 2020. Published online May 20. doi: 10.1001/jamasurg. 2020.1129.
Wang L, Wilson SE, Stewart DB, Hollenbeak CS. Marital status and colon cancer outcomes in U.S. surveillance, epidemiology and end results registries: Does marriage affect cancer survival by gender and stage? Cancer Epidemiol 2011;35:417-22.
Aizer AA, Chen M-H, Parekh A, Choueiri TK, Hoffman KE, Kim SP, et al
. Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiation Oncol Biol Phys 2014;89:756-64.
Aizer AA, Chen M-H, McCarthy EP, Mendu ML, Koo S, Wilhite TJ, et al
. Marital status and survival in patients with cancer. J Clin Oncol 2013;31:3869-76.
Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: A meta-analytic review. PLOS Med 2010;7:e1000316. doi: 10.1371/journal.pmed. 1000316.
Uchino BN. Social support and health: A review of physiological processes potentially underlying links to disease outcomes. J Behav Med 2006;29:377-87.
Sarkinsian N, Gerstel N. Does singlehood isolate or integrate? Examining the link between marital status and ties to kin, friends, and neighbors. J Soc Pers Relatsh 2016;33:361-84.
Kislev E. Happy Singlehood: The Rising Acceptance and Celebration of Solo Living. Berkeley, CA: University of California Press; 2019.
Umberson, D, Williams K, Powers DA, Liu H, Needham B. You make me sick: Marital quality and health over the life course. J Health Soc Behav 2006;47:1-16.
Kahneman D. Thinking, Fast and Slow. NY: Farrar, Straus and Giroux; 2011.
Fazio LK, Brashier NM, Payne BK, Marsh EJ. Knowledge does not protect against illusory truth. J Exp Psychol Gen 2015;144:993-1002.
DePaulo B. Singled Out: How Singles are Stereotyped, Stigmatized, and Ignored, and Still Live Happily Ever After. NY: St. Martin's Press; 2007.
Klinenberg E. Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone. NY: Penguin; 2013.