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  In this article
  Patient Choice
   Availability Heu...
  Outgroup Homogeneity
  Conclusion
   References

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EDITORIAL
Year : 2020  |  Volume : 57  |  Issue : 4  |  Page : 367-369
 

Dispelling myths about unmarried patients with cancer


College of Arts and Sciences, University of Delaware, Newark, DE, United States

Date of Submission09-Feb-2020
Date of Decision25-May-2020
Date of Acceptance27-May-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Joan DelFattore
College of Arts and Sciences, University of Delaware, Newark, DE
United States
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_110_20

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How to cite this article:
DelFattore J. Dispelling myths about unmarried patients with cancer. Indian J Cancer 2020;57:367-9

How to cite this URL:
DelFattore J. Dispelling myths about unmarried patients with cancer. Indian J Cancer [serial online] 2020 [cited 2020 Oct 28];57:367-9. Available from: https://www.indianjcancer.com/text.asp?2020/57/4/367/290269




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.[1]

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 [2] and sex.[3]

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 Top


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.[4] 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.[5] 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.[6] 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.[7] 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.”[8]

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.[9] Moreover, non-spousal relationships have been shown to provide effective functional and emotional support,[10] while stressful marriages are associated with poor health outcomes.[11] 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.[12] Two of these heuristics, availability and outgroup homogeneity, are particularly relevant to the medical literature on marital status and cancer.


  Availability Heuristic Top


Psychologists have known for decades that people's beliefs depend less on data than on the frequent repetition of widely accepted ideas.[13] 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.[14] 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.[15] Moreover, authors of SEER-based medical articles have stated in interviews that they themselves depend on their wives for health care.[16] 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 Top


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.[17] 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 Top


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 Top

1.
DelFattore J. Death by Stereotype? Cancer treatment in unmarried patients. N Engl J Med 2019;381:982-985.  Back to cited text no. 1
    
2.
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.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
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.  Back to cited text no. 5
    
6.
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.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
Uchino BN. Social support and health: A review of physiological processes potentially underlying links to disease outcomes. J Behav Med 2006;29:377-87.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Kislev E. Happy Singlehood: The Rising Acceptance and Celebration of Solo Living. Berkeley, CA: University of California Press; 2019.  Back to cited text no. 10
    
11.
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.  Back to cited text no. 11
    
12.
Kahneman D. Thinking, Fast and Slow. NY: Farrar, Straus and Giroux; 2011.  Back to cited text no. 12
    
13.
Fazio LK, Brashier NM, Payne BK, Marsh EJ. Knowledge does not protect against illusory truth. J Exp Psychol Gen 2015;144:993-1002.  Back to cited text no. 13
    
14.
National Geographic Society. Nat Geographic WILD: What are the odds? Some surprising shark attack stats. Available from: https://blog.nationalgeographic.org/2011/11/22/nat-geo-wild-what-are-the-odds-some-surprising-shark-attack-stats/. [Last accessed on 2020 Jul 06].  Back to cited text no. 14
    
15.
DePaulo B. Singled Out: How Singles are Stereotyped, Stigmatized, and Ignored, and Still Live Happily Ever After. NY: St. Martin's Press; 2007.  Back to cited text no. 15
    
16.
DelFattore J. If you're single with cancer, you may get less aggressive treatment than a married person. Washington Post. Available from: https://www.washingtonpost.com/national/health-science/if-youre-single-with-cancer-you-may-get-less-aggressive-treatment-than-a-married-person/2018/11/30/a1286d20-ce18-11e8-920f-dd52e1ae4570_story.html. [Last accessed on 2020 Jul 06].  Back to cited text no. 16
    
17.
Klinenberg E. Going Solo: The Extraordinary Rise and Surprising Appeal of Living Alone. NY: Penguin; 2013.  Back to cited text no. 17
    




 

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