Elsevier

Gynecologic Oncology

Volume 136, Issue 2, February 2015, Pages 328-335
Gynecologic Oncology

Survival advantage of marriage in uterine cancer patients contrasts poor outcome for widows: A Surveillance, Epidemiology and End Results study

https://doi.org/10.1016/j.ygyno.2014.12.027Get rights and content

Highlights

  • Married women have a lower risk of death from uterine cancer than non-married counterparts.

  • Among non-married patients, widows have a disproportionately high risk of dying from uterine cancer.

  • Psychosocial interventions should be evaluated as part of adjuvant therapy and survivorship programs for widows.

Abstract

Background

Marriage confers a survival advantage for many cancers but has yet to be evaluated in uterine cancer patients. We sought to determine whether uterine cancer survival varied by self-reported relationship status.

Methods

Data were downloaded from the Surveillance, Epidemiology, and End Results program for women diagnosed with uterine cancer (between 1991 and 2010 in nine geographic regions). Patients with complete clinical data for analysis were categorized as married, single, widowed or other (divorced or separated). Differences in distributions were evaluated using Chi-square, exact and/or Mantel–Haenszel test. Uterine cancer survival was analyzed by Kaplan–Meier method with log-rank test and multivariate Cox regression analysis.

Results

Of 47,420 eligible patients, 56% were married, 15% were single and 19% were widows. Married vs. non-married women had a higher likelihood of having low risk (grade 1/2 endometrioid) endometrial cancer and local disease (p < 0.0001), and a reduced risk of cancer death (HR = 0.8, 95% CI = 0.77–0.84). Multivariate evaluation of uterine cancer survival by relationship type indicated that widows consistently had significantly worse uterine cancer survival than single, married and other women in all patients and subset analyses (p < 0.0001).

Conclusion

While marital status is associated with differential uterine cancer survival, evaluation of self-reported relationship by type indicated that the poor outcome observed in widows explained most of the benefit attributed to marriage. This report identifies widows as a new high-risk subpopulation with significantly inferior outcomes potentially benefiting from personalized care and social support.

Introduction

Marital status is associated with a survival advantage among patients with a variety of cancers [1], [2], [3], [4], [5]. A recent study demonstrated that marriage conferred a survival advantage in the ten most lethal cancers in the United States as married patients were less likely to present with metastatic disease, more likely to receive definitive treatment, and less likely to die as a result of their cancer [2]. Among less lethal cancers, such as uterine cancer where the five-year overall survival rate is 82% [6], the impact of self-declared marriage and relationship status on cancer survival is uncertain. Favorable outcomes in uterine cancer are attributed to the fact that most cases are diagnosed at an early stage and aggressive histologic features are relatively rare [6]. Despite the good prognosis associated with most uterine cancers, a certain number of women will ultimately die of their disease, and it is plausible, as with other malignancies, that survival may be affected by marital status and type of relationship.

The incidence of uterine cancer rose 1% annually each of the past 10 years in the United States [7]. That rate is anticipated to increase as the largest proportion of the female population enters the age range of highest risk for this disease, and in 2014 approximately 53,000 new diagnoses and 8590 deaths are expected [8]. This is compounded by rising obesity rates in the United States, predisposing younger women to an increased risk of uterine cancer [9], [10]. Despite a growing disease burden, the influence of self-reported marriage or relationship type on uterine cancer survival has not been well described. One prior large Norwegian multi-site study found no survival advantage associated with marriage among patients with uterine cancer, though overall survival was used as the endpoint rather than uterine cancer survival [11].

If uterine cancer survival varies by marital status or type of relationship, survivorship programs may have the potential to enhance patient outcomes. Understanding the impact of marriage or relationship type on uterine cancer survival and the ability to identify high-risk subpopulations can guide survivorship programs in prioritizing supportive services, personalized clinical management and care, and deployment of meaningful psychosocial interventions. Accordingly, we sought to perform a population-based study to determine whether uterine cancer survival varies by self-reported marital status or type of relationship.

Section snippets

Methods

Data were downloaded from the Surveillance, Epidemiology, and End Results (SEER) program from the National Cancer Institute (NCI) for patients diagnosed in nine geographic regions (Table 1). Patients undergoing surgery for uterine cancer between 1991 and 2010 with age at diagnosis, race, ethnicity, self-reported relationship, site of disease, cell type, stage, grade, cancer survival status and cancer survival time were eligible for this project. The diagnosis of uterine cancer was based on an

Results

Of the 47,420 eligible patients, 56% were married, 15% were single and 19% were widows. Table 1 indicates the characteristics for the eligible patients. The majority of patients were Caucasian race (85%), had disease localized to the uterus or adnexa (76%) and tumors with an endometrioid histology (81%). Only 29% of the patients received radiation therapy.

Married women were less likely to be African American, diagnosed at older age, have metastatic or high-risk disease, and to die of uterine

Discussion

Marital status and type of relationship were both independent prognostic factors for uterine cancer survival in our analysis in over 47,000 women in the SEER program diagnosed between 1991 and 2010 in nine geographical regions. The observation that married patients had a uterine cancer survival advantage relative to those who were not married is consistent with the survival benefit of marriage reported in other cancer sites [1], [2], [3], [4], [5]. Multivariate Cox modeling and Kaplan–Meier

Conflict of interest statement

The authors have no conflicts of interest to report.

Funding source

This research was funded by award W81XWH-11-2-0131 (PI: Chad A. Hamilton) from the U.S. Department of Defense (DOD) through the United States Medical Research and Materiel Command (USAMRMC), and the Telemedicine and Advanced Technology Research Center (TATRC) program.

Disclaimer

The view(s) expressed herein are those of the author(s) and do not reflect the official views of the Department of the Air Force, the Department of the Army, the Department of the Navy, the Department of Defense, or the United States government.

The following are the supplementary data related to this article.

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