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How Being Unmarried Impacts Cancer Treatment: An Interview With Joan DelFattore, PhD, MS

Joan DelFattore, PhD, MS.

Studies have shown that unmarried patients with cancer are less likely to receive surgery and radiotherapy than their married counterparts; they are also less likely to survive their cancer. In a research-based perspective essay published in The New England Journal of Medicine, Joan DelFattore, PhD, MS, a survivor of stage IV gallbladder cancer, suggests that contrary to assumptions made by a number of researchers, the disparities in cancer treatment for individuals who are single may stem not from patient preference but instead from differences in physician treatment recommendations. In this interview with i3 Health, Dr. DelFattore shares her experience as an unmarried patient with cancer and explores how societal perceptions of singleness may affect oncologists' treatment of unmarried patients.

In your personal experience as a patient with cancer, how did the fact that you were unmarried impact oncologists' suggestions for your treatment?

Joan DelFattore, PhD, MS: My own experience was mixed. When I was diagnosed with stage IV gallbladder cancer, I was first treated by a surgeon who accepted a support system based on extended family and friends. But when I saw a medical oncologist about follow-up chemotherapy, he became fixated on my lack of immediate family. Although the standard of care was combination chemotherapy, he recommended only gemcitabine because he wouldn't risk serious side effects with, as he put it, "someone in your situation."

I moved on to another oncologist, who gave me gemcitabine and oxaliplatin. Like the surgeon, she focused not on traditional roles, but on whether competent adults would provide specific services. That was in 2011, and so far there's been no recurrence. Still, those experiences made me wonder how often physicians' social views affect the treatment of unmarried patients.

What did you find lacking in the existing research on how marital status impacts cancer treatment?

Dr. DelFattore: Dozens of articles published between 1987 and 2019 report that patients with cancer are significantly more likely to receive surgery and radiotherapy if they're currently married than if they're widowed, divorced, separated, or never married. The authors speculate that unmarried patients couldn't handle, and don't even want, aggressive treatment.

But research shows that only 0.52% of unmarried patients refuse surgery when it's offered, and 1.33% refuse radiotherapy. Although that's higher than the results for married people, rates below 1% or 2% don't justify the portrayal of unmarried adults as not wanting those treatments.

Similarly, the speculation that unmarried patients lack social support is contradicted by extensive psychological and sociological research—including, ironically, some of the very studies that these medical authors cite. In reality, social support can be understood only as a complex blend of functional, emotional, and perceived connectedness that cannot be reduced to any one factor, such as the presence or absence of a spouse. Research also shows that unmarried adults are likely to have closer ties with family and community than do their married counterparts, and that non-spousal support can be highly effective.

In your article in The New England Journal of Medicine, you ask "whether physicians' implicit beliefs influence research and clinical practice involving unmarried patients with cancer." What implicit beliefs do you suspect may be at play?

Dr. DelFattore: Let me give just a couple of examples. Psychologists speak of a mental shortcut called the availability heuristic, in which people focus on what comes most readily to mind without stopping to think about whether it's representative of the bigger picture. Repetition plays an important role, as people tend to believe what they've heard many times. In the words of Nobel Prize-winning psychologist Daniel Kahneman, "familiarity is not easily distinguished from truth." Although the medical researchers' view of unmarried patients conflicts with the actual data, it's highly consistent with a long-standing, deeply ingrained, marriage-centered cultural narrative.

Another example is outgroup homogeneity, which is the tendency to view members of an outgroup as if they all share the same characteristics. The medical articles I examined present an undifferentiated portrayal of unmarried adults as prone to depression and addiction, unable to follow medical instructions, and lacking social connectedness. Without doubt, some individuals, married as well as unmarried, do fit that profile. But unmarried adults make up 45% of the adult population. The speculations offered to justify the undertreatment of unmarried patients are social stereotypes that cannot possibly apply to nearly half the adults in the country.

What do you feel that oncologists should keep in mind when treating unmarried patients with cancer?

Dr. DelFattore: When I've spoken with physicians about this topic, a common response is that they don't have time to ask about social support, and of course they're right in saying that patient visits are already too short and burdened with record-keeping. But if social support is a determining factor in the treatment decision, it's important to ascertain how much support a patient actually has.

The medical articles I examined are demonstrably incorrect in describing marriage as a proxy for social support—a point that affects married as well as unmarried patients. Of course, the support of a loving spouse can be invaluable in dealing with serious illness. But marriage does not guarantee support, any more than single status is the same as social isolation.

About Dr. DelFattore

Joan DelFattore, PhD, MS, is a Professor Emerita of English and Legal Studies at the University of Delaware. She holds a PhD in English and an MS in Clinical Psychology from Penn State University. Her work on freedom of expression won numerous awards. Since her retirement, Dr. DelFattore's writing has focused on life as a single woman, with an emphasis on coping with serious illness while single. She has given a TEDx talk and has been interviewed on NPR's "All Things Considered;" in addition, she has authored articles for the Washington Post, Herald Tribune, Psychology Today, Health Psychologist, Psych Central, Quartz, Folks Magazine, and The New England Journal of Medicine. She is currently working on a book that combines her personal experience with research on single life.

For More Information

DelFattore J (2019). Death by stereotype? Cancer treatment in unmarried patients. N Engl J Med, 381:982-985. DOI:10.1056/NEJMms1902657

Aizer AA, Chen M, McCarthy EP, et al (2013). Marital status and survival in patients with cancer. J Clin Oncol, 31(31):3869-3876. DOI:10.1200/JCO.2013.49.6489

Aizer AA, Chen MH, Parekh A, et al (2014). Refusal of curative radiation therapy and surgery among patients with cancer. Int J Radiat Oncol Biol Phys, 89(4):756-764. DOI:10.1016/j.ijrobp.2014.03.024

Uchino BN (2006). Social support and health: a review of physiological processes potentially underlying links to disease outcomes. J Behav Med, 29(4):377-387. DOI:10.1007/s10865-006-9056-5

Sarkisian N & Gerstel N (2016). Does singlehood isolate or integrate? Examining the link between marital status and ties to kin, friends, and neighbors. J Soc Pers Relat, 33(3):361-384. DOI:10.1177/0265407515597564

Kislev E (2019). Happy Singlehood: The Rising Acceptance and Celebration of Solo Living. Berkeley, CA: University of California Press.

Kahneman D (2011). Thinking, Fast and Slow. New York, NY: Farrar, Straus and Giroux.

DePaulo, B (2006). Singled Out: How Singles Are Stereotyped, Stigmatized, and Ignored, and Still Live Happily Ever After. New York, NY: St Martin's Griffin.

United States Census Bureau (2017). Unmarried and Single Americans Week: Sept. 17-23, 2017. Available at: https://www.census.gov/newsroom/facts-for-features/2017/single-americans-week.html

Umberson D, Williams K, Powers DA, et al (2006). You make me sick: marital quality and health over the life course. J Health Soc Behav, 47(1):1-16. DOI:10.1177/002214650604700101

DePaulo B (2019). The social lives of single people. Psychology Today. Available at:https://www.psychologytoday.com/us/blog/living-single/201905/the-social-lives-single-people

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