Unmarried vs Never Married
Cultural stereotypes affecting physicians’ recommendations are propped up by what Dr DelFattore described as “a startling lack of rigor in presenting research support to justify assertions for which SEER provides no data.”1 She cited a study from 2013 that claims married patients demonstrate lower rates of depression than unmarried patients, but this study drew its conclusions from a comparison of rates of depression in married vs divorced/separated people rather than comparing married patients to the entire unmarried adult population.1,4 Nonetheless, the authors of this SEER study suggest clinicians should screen all unmarried patients for depression.4
Dr DelFattore’s assessment of research on rates of depression and marital status in the decade preceding publication of the 2013 SEER study, however, do not support these conclusions.1 A 2016 report from the United States Preventive Services Task force suggests screening all patients for depression regardless of risk factors, and implementation of universal depression screening in patients with cancer receiving care at the Mayo Clinic revealed no disparity in rates of depression based on marital status.5,6
In spite of this, SEER-based research results identify depression in unmarried patients with cancer as a characteristic that contributes to the inferior clinical outcomes in these patients, which could impact physician perspective and bias in treating unmarried patients.1
Dr DelFattore next examined research on factors affecting social support in the context of marital status. She noted that when reported separately by sex, analyses of SEER data indicated a stronger correlation between marital status and survival in male vs female patients.1,4,7 This assessment is further supported by the reality that men are more likely to be uninsured than women, but the disparity is even more pronounced in unmarried men.8 Though the benefits of spousal support are likely stratified by sex differences, benefiting men more than women, SEER-based research continues to encourage screening for depression, alcoholism, and smoking in unmarried cancer patients without recommending assessment for nonspousal social support.1
“To be sure, research does show that social support is associated with the ability to handle challenging treatment. But it is not synonymous with marriage, and in attempting to legitimize that conflation, these studies misapply sources that explicitly repudiate single-factor assessments of social support,” explained Dr DelFattore.1
Dr DelFattore cautions against applying results assessing multidimensional social support in the narrowed lens of presence or absence of a spouse, particularly as unmarried adults usually have more friends, a stronger sense of community, and better relationships with extended family than married adults.1
“Without doubt, there are people who are too depressed and isolated to tolerate aggressive treatment, or even to want it. But that characterization cannot possibly apply to nearly half the adult population,” she wrote. Dr DelFattore continued by emphasizing the need to expand research on the implicit biases in clinical care to include marital status and its attendant topics, including living alone and lacking immediate family.1
1. DelFattore J. Death by stereotype? Cancer treatment in unmarried patients. N Engl J Med. 2019;381(10):982-985.
2. United States Census Bureau. Unmarried and single Americans week: Sept. 17-23, 2017 [Profile America Facts for Features]. Washington, DC; August 14, 2017. https://www.census.gov/newsroom/facts-for-features/2017/single-americans-week.html. Last revised August 3, 2018. Accessed December 3, 2019.
3. Aizer AA, Chen MH, Parekh A, et al. Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiat Oncol Biol Phys. 2014;89(4):756-764.
4. Aizer AA, Chen MH, McCarthy EP, et al. Marital status and survival in patients with cancer. J Clin Oncol. 2013;31(31):3869-3876.
5. Siu AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(4):380-387.
6. Shreders A, Niazi S, Hodge D, et al. Universal screening for depression in cancer patients and its impact on management patterns. J Clin Oncol. 2016;34(26 suppl):232.
7. Wang L, Wilson SE, Stewart DB, Hollenbeak CS. Marital status and colon cancer outcomes in US Surveillance, Epidemiology and End Results registries: does marriage affect cancer survival by gender and stage? Cancer Epidemiol. 2011;35(5):417-422.
8. Stimpson JP, Kemmick Pintor J, Wilson FA. Association of Medicaid expansion with health insurance coverage by marital status and sex. PLoS One. 2019;14(10):e0223556.