Effects of Marital Status on Bias, Offered Treatment in Cancer

Treatment for cancer in unmarried patients often results in inferior clinical outcomes, but these results could be due to clinician bias in choosing less intensive therapy and/or foregoing surgery for these patients due to perceived lack of social support.¹

A review and critical assessment written by Joan DelFattore, PhD, professor emerita of English at the University of Delaware in Newark, that reached this conclusion was inspired by her personal experience when she underwent treatment for stage IV gallbladder cancer as a single, unmarried patient. Dr DelFattore emphasized the strength of her social support with her surgical oncologist, even though at the time she was unaware that the presence of such support may have impacted the surgeon’s decision to even operate.¹

After surgery, Dr DelFattore met first with a medical oncologist who only wanted to administer less intensive gemcitabine due, seemingly, to fears that DelFattore lacked the social support that might be important for successfully undergoing more intensive therapy because she is unmarried. Dr DelFattore sought care from a different medical oncologist, and she underwent therapy with the more intensive combination of oxaliplatin plus gemcitabine, a treatment regimen associated with superior clinical outcomes but higher toxicities than gemcitabine alone.¹

This experience resulted in DelFattore questioning what role physicians’ social views affect their treatment recommendations for patients without the traditional support structure of marriage.¹ She examined 84 studies indexed on Medline that use data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database, which categorizes patients by marital status.¹

An Increasing Patient Demographic

According to Dr DelFattore, disentangling the factors affecting treatment and outcomes in married and unmarried patients is urgent: nearly half of American adults are unmarried, and the number continues to grow.^1,2 Dr DelFattore found that unmarried people tend to have more robust social structures, and it seems unlikely that they decline more intensive treatment at a greater rate than their married counterparts.¹ In fact, a study of nearly 1 million patients with cancer found that just 0.52% of unmarried patients declined physician-recommended surgery, and 1.33% declined physician-recommended radiotherapy.³ In married patients, the rates were lower, with 0.24% declining surgery and 0.69% declining radiotherapy, but as Dr DelFattore explained, rates of declining intensive care that fall below 1% or 2% do not support the idea that unmarried patients are likely to decline physician-recommended care, even when that care is intensive.^1,3

Given this lack of evidence for unmarried patients shouldering the responsibility of declining more intensive therapy, the influence of cultural stereotypes on what physicians recommend should be examined. “It is thus reasonable to ask whether physicians’ implicit beliefs influence research and clinical practice involving unmarried patients with cancer,” wrote Dr DelFattore.¹